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Does moderate drinking reduce heart failure risk?

Tue, 20/10/2015 - 12:10

"Seven alcoholic drinks a week can help to prevent heart disease," the Daily Mirror reports. A US study suggests alcohol consumption up to this level may have a protective effect against heart failure.

This large US study followed more than 14,000 adults aged 45 and older for 24 years. It found those who drank up to 12 UK units (7 standard US "drinks") per week at the start of the study had a lower risk of developing heart failure than those who never drank alcohol.

The average alcohol consumption in this lower risk group was about 5 UK units a week (around 2.5 low-strength ABV 3.6% pints of lager a week).

At this level of consumption, men were 20% less likely to develop heart failure compared with people who never drank, while for women it was 16%.

The study benefits from its large size and the fact data was collected over a long period of time.

But studying the impact of alcohol on outcomes is fraught with difficulty. These difficulties include people not all having the same idea of what a "drink" or "unit" is.

People may also intentionally misreport their alcohol intake. We also cannot be certain alcohol intake alone is giving rise to the reduction in risk seen.

Steps you can take to help reduce your risk of heart failure – and other types of heart disease – include eating a healthy diet, achieving and maintaining a healthy weight, and quitting smoking (if you smoke).

 

Where did the story come from?

The study was carried out by researchers from Brigham and Women's Hospital in Boston, and other research centres in the US, the UK and Portugal.

It was published in the peer-reviewed European Heart Journal.

The UK media generally did not translate the measure of "drinks" used in this study into UK units, which people might have found easier to understand.

The standard US "drink" in this study contained 14g of alcohol, and a UK unit is 8g of alcohol. So the group with the reduced risk actually drank up to 12 units a week.

The reporting also makes it seem as though 12 units – what is referred to in the papers as "a glass a day" – is the optimal level, but the study cannot not tell us this.

While consumption in this lower risk group was "up to" 12 units per week, the average consumption was about 5 units per week. This is about 3.5 small glasses (125ml of 12% alcohol by volume) of wine a week, not a "glass a day".

And the poor old Daily Express got itself into a right muddle. At the time of writing, its website is actually running two versions of the story. 

One story claims moderate alcohol consumption was linked to reduced heart failure risk, which is accurate. 

The other story claims moderate alcohol consumption protects against heart attacks, which is not accurate, as a heart attack is an entirely different condition to heart failure.

 

What kind of research was this?

This was a large prospective cohort study looking at the relationship between alcohol consumption and the risk of heart failure.

Heavy alcohol consumption is known to increase the risk of heart failure, but the researchers say the effects of moderate alcohol consumption are not clear.

This type of study is the best way to look at the link between alcohol consumption and health outcomes, as it would not be feasible (or arguably ethical) to randomise people to consume different amounts of alcohol over a long period of time.

As with all observational studies, other factors (confounders) may be having an effect on the outcome, and it is difficult to be certain their impact has been entirely removed.

Studying the effects of alcohol intake is notoriously difficult for a range of reasons. Not least is what can be termed the "Del Boy effect": in one episode of the comedy Only Fools and Horses, the lead character tells his GP he is a teetotal fitness fanatic when in fact the opposite is true – people often misrepresent how healthy they are when talking to their doctor.

 

What did the research involve?

The researchers recruited adults (average age 54 years) who did not have heart failure in 1987 to 1989, and followed them up over about 24 years.

Researchers assessed the participants' alcohol consumption at the start of and during the study, and identified any participants who developed heart failure.

They then compared the likelihood of developing heart failure among people with different levels of alcohol intake.

Participants came from four communities in the US, and were aged 45 to 64 years old at the start of the study. The current analyses only included black or white participants. People with evidence of heart failure at the start of the study were excluded.

The participants had annual telephone calls with researchers, and in-person visits every three years.

At each interview, participants were asked if they currently drank alcohol and, if not, whether they had done so in the past. Those who drank were asked how often they usually drank wine, beer, or spirits (hard liquor).

It was not clear exactly how participants were asked to quantify their drinking, but the researchers used the information collected to determine how many standard drinks each person consumed a week.

A drink in this study was considered to be 14g of alcohol. In the UK, 1 unit is 8g of pure alcohol, so this drink would be 1.75 units in UK terms.

People developing heart failure were identified by looking at hospital records and national death records. This identified those recorded as being hospitalised for, or dying from, heart failure.

For their analyses, the researchers grouped people according to their alcohol consumption at the start of the study, and looked at whether their risk of heart failure differed across the groups.

They repeated their analyses using people's average alcohol consumption over the first nine years of the study.

The researchers took into account potential confounders at the start of the study, including:

  • age
  • health conditions, including high blood pressure, diabetes, coronary artery disease, stroke and heart attack
  • cholesterol levels
  • body mass index (BMI)
  • smoking
  • physical activity level
  • educational level (as an indication of socioeconomic status)

 

What were the basic results?

Among the participants:

  • 42% never drank alcohol
  • 19% were former alcohol drinkers who had stopped
  • 25% reported drinking up to 7 drinks (up to 12.25 UK units) per week (average consumption in this group was about 3 drinks per week, or 5.25 UK units)
  • 8% reported drinking 7 to 14 drinks (12.25 to 24.5 UK units) per week
  • 3% reported drinking 14 to 21 drinks (24.5 to 36.75 UK units) per week
  • 3% reported drinking 21 drinks or more (36.75 UK units or more) per week

People in the various alcohol consumption categories differed from each other in a variety of ways. For example, heavier drinkers tended to be younger and have lower BMIs, but be more likely to smoke.

Overall, about 17% of participants were hospitalised for, or died from, heart failure during the 24 years of the study.

Men who drank up to 7 drinks per week at the start of the study were 20% less likely to develop heart failure than those who never drank alcohol (hazard ratio [HR] 0.80, 95% confidence interval [CI] 0.68 to 0.94).

Women who drank up to 7 drinks per week at the start of the study were 16% less likely to develop heart failure than those who never drank alcohol (HR 0.84, 95% CI 0.71 to 1.00).

But at the upper level of the confidence interval (1.00), there would be no actual difference in risk reduction.

People who drank 7 drinks a week or more did not differ significantly in their risk of heart failure compared with those who never drank alcohol.

Those who drank the most (21 drinks per week or more for men, and those drinking 14 drinks per week or more for women) were more likely to die from any cause during the study.

 

How did the researchers interpret the results?

The researchers concluded that, "Alcohol consumption of up to 7 drinks [about 12 UK units] per week at early middle age is associated with lower risk for future HF [heart failure], with a similar but less definite association in women than in men."

 

Conclusion

This study suggests drinking up to about 12 UK units a week is associated with a lower risk of heart failure in men compared with never drinking alcohol.

There was a similar result for women, but the results were not as robust and did not rule out the possibility of there being no difference.

The study benefits from its large size (more than 14,000 people) and the fact it collected its data prospectively over a long period of time.

However, studying the impact of alcohol on outcomes is fraught with difficulty. These difficulties include people not being entirely sure what a "drink" or a "unit" is, and reporting their intakes incorrectly as a result.

In addition, people may intentionally misreport their alcohol intake – for example, if they are concerned about what the researchers will think about their intake.

Also, people who do not drink may do so for reasons linked to their health, so may have a greater risk of being unhealthy.

Other limitations are that while the researchers did try to take a number of confounders into account, unmeasured factors could still be having an effect, such as diet.

For example, these confounders were only assessed at the start of the study, and people may have changed over the study period (such as taking up smoking). 

The study only identified people who were hospitalised for, or died from, heart failure. This misses people who had not yet been hospitalised or died from the condition.

The results also may not apply to younger people, and the researchers could not look at specific patterns of drinking, such as binge drinking.

Although no level of alcohol intake was associated with an increased risk of heart failure in this study, the authors note few people drank very heavily in their sample. Excessive alcohol consumption is known to lead to heart damage.

The study also did not look at the incidence of other alcohol-related illnesses, such as liver disease. Deaths from liver disease in the UK have increased 400% since 1970, due in part to increased alcohol consumption, as we discussed in November 2014.

The NHS recommends that:

  • men should not regularly drink more than 3-4 units of alcohol a day
  • women should not regularly drink more than 2-3 units a day
  • if you've had a heavy drinking session, avoid alcohol for 48 hours

Here, "regularly" means drinking this amount every day or most days of the week.

The amount of alcohol consumed in the study group with the reduced risk was within the UK's recommended maximum consumption limits.

But it is generally not recommended that people take up drinking alcohol just for any potential heart benefits. If you do drink alcohol, you should stick within the recommended limits.

Analysis by Bazian. Edited by NHS Choices. Follow Behind the Headlines on Twitter. Join the Healthy Evidence forum.

Links To The Headlines

Seven alcoholic drinks a week can help to prevent heart disease, new research reveals. Daily Mirror, January 20 2015

A drink a day 'cuts heart disease risk by a fifth' researchers claim...so don't worry about having a dry January. Mail Online, January 19 2015

A drink a night 'is better for your heart than none at all'. The Independent, January 19 2015

Glass of wine a day could protect the heart. The Daily Telegraph, January 20 2015

Daily drink 'cuts risk' of middle-age heart failure. The Times, January 20 2015

Drinking half a pint of beer a day could fight heart failure. Daily Express, January 20 2015

Links To Science

Gonçalves A, Claggett B, Jhund PS, et al. Alcohol consumption and risk of heart failure: the Atherosclerosis Risk in Communities Study. European Heart Journal. Published online January 20 2015

Categories: NHS Choices

Nose balloon could be used to treat glue ear

Tue, 28/07/2015 - 13:00

"Using the nose to inflate a balloon helps heal glue ear," BBC News reports. The technique, known as autoinflation, was found to be effective in around half of cases of this common childhood ear condition.

Glue ear is when the middle ear becomes filled with fluid. It is common among young children and can cause hearing problems. Most cases get better without treatment, but sometimes hearing aids or grommets (small tubes inserted into the eardrum to drain fluid) may be used.

Autoinflation is where a child blows into a special balloon with their nose. It is not a new concept, but research into its effectiveness compared with other treatments for glue ear – which usually boils down to "watch and wait" – has been lacking.

More than 300 children were included in the study and received autoinflation (three times daily for one to three months) in addition to usual care or usual care alone (control). After one month, 47.3% of the autoinflation group were diagnosed as having normal hearing, compared with 35.6% in the control group.

Autoinflation will only provide a solution for children who are able to inflate the nasal balloon and can do so on a regular, daily basis. This means it may not be suitable for everyone. The technique should not be used without medical supervision and training.

Where did the story come from?

The study was carried out by researchers from the University of Southampton and the University of Oxford.

Funding was provided by the Health Technology Assessment of the National Institute for Health Research.

It was published in the peer-reviewed Canadian Medical Association Journal and has been made available on an open-access basis, so it is free to read online or download as a PDF.

This study has been reported accurately by BBC News and the Daily Mirror, although the reporting gives the impression autoinflation is a new technique. In fact the technique has been used for decades, but there has been persistent controversy about whether it is effective or not. 

What kind of research was this?

This was a randomised controlled trial (RCT) to assess the effectiveness of autoinflation in the treatment of children with glue ear.

Glue ear is when the middle ear becomes filled with fluid. It is quite common among young children – the study reports that up to half of children have been affected by the age of four to five – and can cause problems with hearing and sometimes speech and language development.

The exact cause isn't always clear, but it may be the result of previous ear infection or irritation from environmental allergic substances or smoke.

Most cases get better without treatment, but sometimes hearing aids or grommets may be used. Autoinflation, where the child blows into a special balloon with their nose, is another treatment option.

A randomised controlled study design is the best way to assess the effect of a treatment.  

What did the research involve?

This study included 320 children aged 4 to 11 with glue ear and a recent (past three months) history of hearing loss or other relevant ear-related problems. The children were recruited from 43 general practices in the UK between January 2012 and February 2013.

They were randomly assigned to autoinflation three times daily for between one and three months in addition to usual care, or usual care only (control).

Assessment of middle ear fluid was made at between one and three months by an expert who was unaware of which treatment the children received.

Ear-related quality of life was compared with the baseline values – essentially, the impact any hearing loss had on day-to-day living for each child. Data from weekly symptom diaries related to glue ear was summarised according to the number of days with symptoms.  

What were the basic results?

Baseline characteristics were similar in the two groups. The children who received autoinflation had better outcomes – 47% had no symptoms at one month, compared with 35% in the control group. At three months, the condition had cleared up in 50% in the autoinflation group, compared with 38% in the control group.

It was calculated that nine children would need to be treated with autoinflation for one additional child to benefit from the treatment, compared with what would be expected for usual care. In other words, autoinflation had a number needed to treat (NNT) of nine.

Further analyses found age (above or below 6.5 years), the severity of the symptoms, quality of life or gender had no effect on treatment outcome. Autoinflation increased ear-related quality of life, with children having fewer days with symptoms at one and three months than the usual care group.

Adverse effects were generally similar in both groups, with nosebleeds occurring most frequently (15% and 14% in each group). Mild respiratory tract infections (such as a runny nose) were more common in the autoinflation group, with 15% of children affected, compared with 10% in the control group.  

How did the researchers interpret the results?

The researchers concluded that, "Autoinflation in children aged 4 to 11 years with otitis media with effusion [glue ear] is feasible in [general practice] and effective both in clearing effusions and improving symptoms and ear-related child and parent quality of life." 

Conclusion

This RCT aimed to assess the use of autoinflation as a treatment for glue ear. More than 300 children were included in the study and were randomly assigned to receive autoinflation, in addition to usual care for up to three months, or usual care alone.

The use of autoinflation does appear to show some promise at one and three months, and the side effects were generally mild. However, this will only provide a solution for children who are able to perform the technique and do this regularly. This means it may not be a suitable treatment for everyone.

This study's main strength is that it included a representative sample of the UK population. The researchers conducted a power calculation to ensure they had enrolled a sufficient number of participants to increase the certainty of their findings.

Group assignment was also random, which reduces the risk of bias, and the analysis was by assigned group, with fairly low drop-out (8% at one month and 12% at three months).

Participants were not blinded to the treatment they were receiving, but this is not really possible with this type of intervention. However, the investigators assessing the outcome of the treatment were blinded, which is a strength.

However, the study only assessed school-age children, who were more likely to be able to perform autoinflation, and does not address very young children with glue ear.

This study also cannot inform us how autoinflation may compare with other treatments, such as the use of hearing aids or grommets, particularly in the longer term.  

Overall, this study has provided some positive results, which should be confirmed by a larger study over a longer period of time that also involves younger children.

The treatment does have the advantage of being relatively cheap and non-invasive. It could be a useful first-line treatment as part of a step-wise approach to treat glue ear. If it proves ineffective in individual cases, other treatments such as grommets could then be used.

Links To The Headlines

Blowing balloons 'treats glue ear'. BBC News, July 28 2015

Does your child suffer from glue ear? There could be a very simple way to cure it. Daily Mirror, July 27 2015

Links To Science

Williamson I, Vennik J, Harden A, et al. Effect of nasal balloon autoinflation in children with otitis media with effusion in primary care: an open randomized controlled trial. Canadian Medical Association Journal. Published online July 27 2015

Categories: NHS Choices

The placebo effect can still work, even if people know it's a placebo

Mon, 27/07/2015 - 14:30

"The placebo effect is real – even if you know the treatment you've been given has no medical value, research has concluded," the Mail Online reports. The study in question aimed to further understand how placebos – inactive or dummy treatments – work.

The research involved 40 volunteers who took part in a series of experiments where a heat sensor was applied to their arm. Before the heat application, petroleum gel (Vaseline) was applied to the skin. The researchers added a blue dye to one of the batches and told the volunteers it was a pain relief gel.

The researchers ran a series of conditioning tests where they applied the blue gel or the plain gel to the skin before the heat. What they were actually doing was applying low heat after the blue gel and high heat after the plain gel.

The longer this "conditioning" went on, the greater effect it had. Even when the dyed blue gel was revealed as an identical inactive gel, some pain relief was still experienced by those who had four days of this conditioning, compared with people who had only one day.

While interesting, the study has limited direct applications. The results cannot easily inform the effect a placebo may or may not have in real-life situations.

However, the results reinforce the notion the psychological can have just as big an impact as the physical when it comes to coping with chronic pain

Where did the story come from?

The study was carried out by researchers from the University of Colorado Boulder and the University of Maryland Baltimore in the US, and was funded by the National Institute of Mental Health.

It was published in the peer-reviewed Journal of Pain.

The Mail has a simplistic take on what was quite a complex experimental study and analysis. Its reporting could benefit from recognising the limitations of this experimental research. 

What kind of research was this?

This experimental study aimed to investigate how placebo (inactive) painkillers work.

The researchers explain how recent research has suggested placebo pain relief is mediated by expectations. "Expectancy theory" implies a belief in the placebo is essential for it to work.

This study aimed to see whether placebo painkillers would work if the person was aware they were only receiving placebo, by testing the effects before and after use.

The researchers believed it was all to do with expectancy – if there was enough prior conditioning, the placebo's effect would still persist, even if was later revealed as a placebo. 

What did the research involve?

This experimental study recruited 54 adults (30 men and 24 women aged 18 to 55) via university advertisements.

They were given an initial test to assess their pain response to a thermal stimulus that would be used during the experiments. Those that did not find it sufficiently painful were excluded, leaving 40 participants (27 women and 13 men).

The participants were told they were taking part in a test comparing the painkilling effects of a cream containing an active painkilling ingredient (the placebo) with a cream containing no active ingredients (the control).

Both creams were in fact the same petroleum jelly containing no active ingredients – the only difference being the placebo was blue.

The experiments were in four stages: calibration, placebo manipulation, conditioning, and testing.

Calibration phase

Sixteen different temperature stimuli were given on eight sites of the volunteers' forearms. They were asked to respond on a visual analogue scale from 0 (no pain) to 100 (worst pain imaginable).

From this, six temperatures were derived for each individual for the remaining experiment: two low, two medium, and two high pain stimuli.

Placebo manipulation

The participants were told about the composition of the placebo cream, the active ingredients it contained and possible side effects.

Conditioning

This involved sessions where the person was given either the placebo or control cream before having the heat stimulus applied.

The difference was each time they gave "the placebo" the researchers followed this up by applying a low-heat stimulus, whereas when they gave "the control" they followed this up with a high-heat stimulus.

The participants had been divided into two groups of 20: a short group, who had only one conditioning session, and a long group, who had this conditioning given on four separate days.

Testing

This began after the last conditioning session. Participants were given a few runs with the placebo and control creams, each time being asked to assess on the visual scale how much pain relief they expected to receive with the coming heat stimulus.

The placebo was then revealed to be inactive and identical to the control cream. After a 15-minute delay, they were again tested with the placebo and control creams. 

The researchers compared differences between the creams in expected pain relief before and after the reveal, and with the effect of the short or long conditioning.  

What were the basic results?

The analysis of this study was in-depth. In brief, before the reveal, expected pain relief was higher for placebo than the control cream. This was not significantly different between conditioning groups.

After the reveal, the expected pain relief from the placebo varied among the long conditioning and short conditioning groups. There was some pain relief expectation in the long conditioning group, but there was none in the short conditioning group.

Expected pain relief for the control cream ratings did not change after the placebo reveal, and was no different between the short and long conditioning groups. 

How did the researchers interpret the results?

The researchers concluded their study "demonstrates a form of placebo analgesia that relies on prior conditioning rather than current expected pain relief".

This, they say, "highlights the importance of prior experience on pain relief and offers insight into the variability of placebo effects across individuals".  

Conclusion

This experimental study suggests reinforcing an expectation of a positive outcome – as with the long conditioning in this study – can create a placebo effect. Some pain relief seemed to be experienced, even when the placebo was finally revealed to be as inactive as the control.

In terms of any implications from these findings, there are a few points to bear in mind.

  • This was a fairly small, select group of healthy adults. In fact, they were preferentially selected from the group of volunteers as being people who experienced sufficient pain response to the heat stimulus. They are not representative of everyone, and the results could have been different in other groups.
  • This was a very experimental scenario involving a heat sensor applied to the skin. The participants knew the cause of the pain, their health was not under threat, and they were in a safe environment. This cannot be applied to real-life pain scenarios such as illness or trauma, which can obviously involve widely different forms of pain and severity, and may also involve other symptoms and emotional effects. Placebo pain relief – either applied to the skin, or taken in other forms, such as a tablet or injection – may be completely ineffective in real-life pain situations, regardless of how much the person is conditioned or manipulated to believe it will have an effect.
  • The study's results also cannot be applied to placebos used in other circumstances aside from pain relief – for example, when used in trials as an inactive comparison group to a new drug used to treat disease.   

Overall, this experimental study will be of interest in the fields of psychology and pharmacology for understanding how placebos may have effects through the expectation they will work.

If you are being troubled by chronic pain, you should contact your GP. The NHS runs pain clinics that can provide both physical and psychological advice.  

Links To The Headlines

The placebo effect IS real - even when patients know the treatment they are getting is fake. Mail Online, July 26 2015

Links To Science

Schafer SM, Colloca L, Wagner TD. Conditioned Placebo Analgesia Persists When Subjects Know They Are Receiving a Placebo. The Journal of Pain. Published online January 22 2015

Categories: NHS Choices

Is there really a middle-class drinking 'epidemic' in over-50s?

Fri, 24/07/2015 - 14:00

"Middle-class over-50s have become a generation of problem drinkers," the Mail Online reports – a headline that actually has little basis in fact.

This follows the analysis of more than 9,000 adults aged over 50 from the English Longitudinal Study of Ageing. It found that over-50s falling into a "higher-risk drinking" category were more likely to have middle-class traits such as high educational achievement, better self-rated health, and being socially active.

Higher-risk drinking was defined as drinking more than 50 alcohol units per week (equivalent to five or more bottles of wine) for men, and over 35 units per week (three-and-half bottles of wine) for women.

The Mail's headline got the wrong idea though, because only 3-7% of over-50s drank at these "higher-risk" levels. While an obvious issue of concern, it a stretch to say this is a generation of problem drinkers.

There were also significantly different patterns between men and women. For example, higher-risk drinking was linked to higher income, but only in women.

These uncertainties aside, the study does reinforce the fact that alcohol misuse and the risks of drinking too much do not respect class boundaries. You can do just as much damage by drinking champagne to excess as you can by drinking cheap cider.

 

Where did the story come from?

The study was carried out by Professor José Iparraguirre from the Research Department of Age UK and was also funded by Age UK.

The study was published in the peer-reviewed medical journal BMJ Open. This is an open-access journal, meaning anyone is free to read the study online.

The Mail, The Daily Telegraph, The Times and The Guardian reported the research facts accurately, although none discussed any limitations associated with the research. All papers carried useful quotes from independent experts. For example, the Mail included a quote from Professor Sir Ian Gilmore, chairman of the Alcohol Health Alliance, who said: "Whilst it may be true that middle-class drinkers are able to offset some health problems because of healthier diets and lifestyles more generally, the risks of serious health harms are still significant. For example, even low levels of drinking increase the risk of developing cancer."

 

What kind of research was this?

This was an analysis of a longitudinal survey of ageing, estimating what risk factors might be linked to harmful alcoholic drinking in over-50s.

longitudinal study involves repeated measures over time, so is great for measuring changes in drinking behaviour. One of the disadvantages is that they tend to rely on self-reported survey estimates of alcohol intake, which can be an unreliable reporting method. Some people may deliberately under-report their drinking habits out of embarrassment or social pressure. Others might under or overestimate them by accident through not knowing how many units are in their drinks. Heavy drinkers may forget how much they drank over the course of their sessions.

By using lots of people, over and underestimates should even out to give a relatively accurate picture of what’s going on, but this is never perfect. 

 

What did the research involve?

Researchers analysed the drinking habits of 9,251 adults aged over 50, looking for links between their drinking habits and their income, lifestyle and social situation.

The drinking and other lifestyle information came from responses to the English Longitudinal Study of Ageing. This gathered data from a representative sample of UK men and women aged 50 and over from 2008 to 2011.

Their definition of harmful drinking used the highest risk category from NICE guidelines. This is called "higher-risk drinking" and describes men drinking more than 50 alcohol units per week, or women drinking more than 35 units per week. For men, this is equivalent to five or more bottles of wine a week, or 16 pints or more of strong lager, and equivalent to three-and-half bottles of wine, or 11 pints or more of strong lager for women.

They used two sources of alcohol unit measures, to see if that made any difference to the findings. The first calculated that:

  • one pint of normal-strength beer was equivalent to two units
  • a 175ml glass of wine is equivalent to two units
  • a 250ml glass of wine is equivalent to three units

The second, using the drinkaware website, calculated that:

  • one glass of wine was equivalent to three units
  • one pint of beer was equal to three units

The analysis estimated how the risk of harmful drinking was influenced by:

  • age
  • income
  • education
  • lifestyle (diet, smoking and physical activity levels)
  • depression
  • loneliness
  • self-reported health (poor to excellent)
  • marital status
  • caring responsibilities
  • children in the home
  • employment
  • social isolation

The researchers looked for a link between heavier drinking and people quitting the longitudinal survey. They found no link, suggesting that people dropping out were not an important issue.

 

What were the basic results?

The results showed different patterns for men and women:

  • The risk of women being in the higher-risk drinking category reduced steadily from the ages of 50 to 90.
  • By contrast, men’s risk peaked in their mid-60s, before declining.
    For both sexes, reporting better health,
  • Achieving higher educational attainment and smoking were linked to being in the higher-risk drinking category.
  • Income was linked to higher-risk drinking in women, but not men.
  • Having a job had no link overall. But retirement increased the chances of drinking at higher risk levels for women.
  • Being single, separated or divorced was linked to being in the higher-risk drinking category, although only for men.
  • Loneliness and depression are not associated with higher-risk drinking.
  • Having caring responsibilities reduces the probability of being at higher risk for women.

Some of the analysis looked at how likely people were to enter the higher-risk category from lower drinking levels over a two-year period. This found:

  • For women, being younger and having a higher income increased the probability of becoming a higher-risk alcohol drinker over time.
  • For men, not eating healthily, being younger and having a higher income increase the probability of becoming a higher-risk alcohol drinker

 

How did the researchers interpret the results?

The researchers attempted to draw some themes from their many individual results: "… we can sketch – at the risk of much simplification – the problem of harmful alcohol drinking among people aged 50 or over in England as a middle-class phenomenon: people in better health, higher income, with higher educational attainment and socially more active are more likely to drink at harmful levels."

They say the concept of: "successful ageing […] embraces components such as non-smoking, greater physical activity, more social contacts, better self-rated health and absence of depression, among others." And that their results show: "generally speaking, people aged 50 or over ageing 'successfully' in England are more at risk of drinking at harmful levels".

 

Conclusion

This study showed that higher-risk drinking was linked to a number of factors the researchers described as "middle-class", like higher educational attainment, being socially active and good ratings of health.

Professor Jose Iparraguirre, author of the research, said in the Guardian: "Because this group is typically healthier than other parts of the older population, they might not realise that what they are doing is putting their health in danger".

There are a few reasons to be cautious with these findings.

The study produced a lot of results, so there is a risk some were chance findings. This is particularly relevant, as the analysis focused on higher-risk drinking. Of the large number of people taking part in this survey, only a small chunk (3-7%) fell into this category. Analyses based on these smaller numbers are more likely to give chance findings.

Also, the study only tracked people for a maximum of three years, which isn’t particularly long. Studies tracking drinking behaviour over longer periods of time might show different patterns.

The study used a representative group of UK older adults, which is a strength. However, we can’t be sure this paints a totally realistic picture across the UK, as there may be geographical variation.

The researchers tell us that heavy drinking in older age is linked to death in the short term. This means there was a risk of higher-than-normal numbers of older moderate drinkers, as heavy drinkers might have died earlier. Usefully, the researchers re-ran the stats using an age cut-off of 70. This showed no difference to the age 90 cut-off used for the main analysis, meaning this wasn’t an important influencing factor.

Rosanna O’Connor, director of Alcohol Drugs and Tobacco at Public Health England, said in the Guardian: "Around one in five adults regularly drinks at levels that can damage their health, leading to serious, but preventable, conditions such as stroke, some cancers, depression and liver disease. Many are unaware of the harm caused, especially from drinking frequently throughout the week."

The NHS Health Check, which is available to everyone in England aged 40-74, includes an alcohol risk assessment and advice for those whose drinking may be putting their health at risk.  

Links To The Headlines

Middle class drink epidemic: Affluent over-50s 'sleep-walking' into health crisis by being most likely to consume harmful levels of alcohol each week. Mail Online, July 24 2015

Older people drinking at harmful levels is a 'hidden middle class phenomenon' say experts. The Independent, July 24 2015

'Hidden Alcohol Problem' In Affluent Over 50s. Sky News, July 24 2015

Harmful drinking is a ‘middle-class phenomenon’. The Daily Telegraph, July 24 2015

Harmful drinking among middle-class over-50s is a 'hidden phenomenon'. The Guardian, July 24 2015

Alcohol epidemic: Over 50s who 'have it all' are drinking themselves into an early grave. Daily Express, July 24 2015

Harmful Drinking Among Over-50s Branded 'Middle Class Phenomenon' By Researchers. The Huffington Post, July 24 2015

Links To Science

Iparraguirre J, Socioeconomic determinants of risk of harmful alcohol drinking among people aged 50 or over in England. BMJ Open. Published online July 23 2015

Categories: NHS Choices

Study says 'size really doesn’t matter' when it comes to a penis

Thu, 23/07/2015 - 13:30

"Scientists claim they've worked out what makes the perfect penis," The Independent reports.

According to Swiss researchers, women value overall cosmetic appearance of a penis over length.

The actual point of the study was to assess women's perception of the penises of men who have had surgery for hypospadias, a condition where the hole through which urine passes (meatus) is not at the tip of the penis. The condition is typically corrected in childhood by surgery.

Researchers asked women to compare pictures of men who have been treated for hypospadias with men who had been circumcised.

Overall general penile appearance was found to be the most important aspect of a penis for women and the position and shape of the meatus to be the least important.

Out of a list of eight aspects, the length of a penis was actually rated as coming sixth out of eight. Research suggests a massive disconnect between what men think is important about their penis and what women actually think. One study found that 85% of women were satisfied with their partner's penis size, while only 55% of their corresponding partners felt the same. 

Where did the story come from?

The study was carried out by researchers from University Children’s Hospital Zurich and the University of Zurich. The source of funding was not reported.

The study was published in the peer-reviewed Journal of Sexual Medicine on an open-access basis, so the study is available to read online or download as a PDF (as an advanced warning, the study does contain some graphic images of different types of penises).

This story has been reported accurately in the media with quotes from authors and a detailed report of study findings.

Much of the reporting on the study takes a lighthearted tone, but it is important not to discount the anxieties that many men, usually without justification, experience about penis size. Read more advice about penis size.

Links To The Headlines

Scientists claim they've worked out what makes the perfect penis. The Independent, July 22 2015

Why your penis size doesn't matter (but appearance does). The Daily Telegraph, July 22 2015

Is YOUR penis 'good looking'? Medical study reveals what women really rate as important (and it's NOT length). Mail Online, July 22 2015

Links To Science

Ruppen-Greeff NK, Webber DM, Gobet R, et al. What is a Good Looking Penis? How Women Rate the Penile Appearance of Men with Surgically Corrected Hypospadias. The Journal of Sexual Medicine. Published online July 20 2015

Categories: NHS Choices

Unhealthy thinking about body and weight 'can start in childhood'

Thu, 23/07/2015 - 12:40

"Basis for eating disorders found in children as young as eight," The Guardian reports. A new UK survey of around 6,000 children found the roots of unhealthy thinking about body and weight can predate adolescence.

Researchers collected data from 6,140 boys and girls aged 14 years as part of an ongoing study into childhood health. Information had already been collected from the same group of children about a range of factors, including their body dissatisfaction, body mass index (BMI) and self-esteem, and whether there was a history of maternal eating disorders and family economic disadvantage.

The study reported childhood body dissatisfaction, weight and shape concern, and pressure to lose weight were all significantly higher in girls compared with boys. This predicted eating disorders in girls at age 14. Higher childhood self-esteem seemed to have a protective effect against teenage eating disorders, particularly in boys. 

This study has both strengths and limitations. One of the biggest strengths is its size. It also assessed early risk factors in childhood before the onset of eating disorder behaviours.

However, though the study demonstrates associations, it does not prove causation. There was also a high drop-out rate – only 59% of children completed assessments at the age of 14. This means the results may not be representative. 

Where did the story come from?

The study was carried out by researchers from the University College London Institute of Child Health, the London School of Hygiene and Tropical Medicine, and King's College London in the UK, and Boston Children's Hospital and Harvard Medical School in the US.

It was jointly funded by the National Institute of Health Research (NIHR) and Wellchild.

The study was published in the peer-reviewed British Journal of Psychiatry on an open-access basis. It is free to read online or download as a PDF.

Overall, the UK media reported the story accurately, although some of the limitations were not fully explained.

The Guardian included a useful quote from Lorna Garner, chief operating officer at eating disorders charity, Beat: "It is evidence that one of the causes or contributing factors towards an eating disorder or something that could trigger an eating disorder is the whole thing around body image and self-esteem.

"It doesn't cause it, but it could be a large influencing factor. It is almost as though seeds that are sown pre-teens come to fruition later.

"Knowing that is incredibly helpful because it gives everybody who is involved with wanting to prevent and manage eating disorders an indication that we need to start earlier." 

What kind of research was this?

This population-based prospective cohort study aimed to investigate the prevalence of eating disorder behaviours in 14-year-old children, and how this may be associated with childhood, physical and parental risk factors.

The data source for this study was the Avon Longitudinal Study of Parents and Children, which recruited all pregnant women in Avon in the UK who were expected to have a baby between April 1 1991 and December 31 1992.

Prospective cohort studies like this one, which follow a group of people over time, are useful for looking at how different exposures may be associated with different outcomes.

They can suggest the possible causal chain of a problem, but cannot definitely prove cause and effect because unmeasured factors (confounders) could be involved in the relationship.  

What did the research involve?

This research involved a group of 6,281 children who completed assessment at the age of 14. This was representative of 59% of people taking part in the cohort.

At age 14, eating disorder behaviours were assessed using the Youth Risk Behaviour Surveillance System questionnaire.

Binge eating was assessed using a two-part question where the participants were asked about how often they had eaten a very large amount of food during the past year. Those who answered "yes" were asked a second question about whether they felt out of control during these episodes.

Purging was assessed by asking how often in the past year participants made themselves sick or used laxatives to lose weight or avoid gaining weight.

Weight and shape concerns were also assessed at 14 years using three questions as part of another survey:

  • In the past year, how happy have you been with the way your body looks?
  • In the past year, how much has your weight made a difference to how you feel about yourself?
  • In the past year, how much have you worried about gaining a little weight (as little as 1kg)?

Pressure to lose weight (from peers, family, the media, for example) was also assessed using another scale. Childhood and parental risk factors were assessed in earlier childhood.

At the age of 10.5 years, body dissatisfaction was assessed using gender-appropriate rating scales, and body mass index (BMI) was obtained from direct assessment. Self-esteem was also assessed using another scale.

Data on family financial problems was obtained from maternal reports at regular intervals throughout childhood by means of questionnaires.

Data was also collected on maternal eating disorder when the mothers were pregnant by asking them if they ever experienced anorexia nervosa or bulimia nervosa.

The researchers used various statistical methods to investigate the association between each predictor and outcome, divided by gender. 

What were the basic results?

Body dissatisfaction, weight and shape concern, and reported pressure to lose weight were all significantly higher in girls compared with boys.

Prevalence of eating disorder behaviours and cognition at 14
  • 18% of girls and 3% of boys reported they felt quite a lot of pressure from the media to lose weight
  • 40% of girls and 12% of boys reported dieting in the previous year
  • 7.5% of girls and 3.5% of boys reported bingeing
  • 7.6% of girls and 1.6% of boys reported frequent dieting
  • 0.4% of boys and 0.5% of girls reported they binged and dieted
Predictors of eating disorder cognitions
  • Maternal eating disorder with a history of both anorexia and bulimia nervosa predicted greater adolescent body dissatisfaction in girls, but not in boys.
  • Weight and shape concern in the maternal eating disorder group was higher in 14-year-old girls compared with boys.
  • Family economic conditions affected both girls and boys.
Eating disorder behaviours
  • Maternal lifetime anorexia and bulimia and economic disadvantage predicted dieting in boys, but not in girls.
  • Family economic disadvantage was associated with bingeing in both boys and girls. Overall, higher self-esteem was associated with lower odds of bingeing in girls.
  • Higher self-esteem at eight years old was associated with lower odds of purging in boys. A high odds of purging was noticed in maternal lifetime eating disorder group children.  
How did the researchers interpret the results?

Researchers said that, "We identified a strong effect of childhood body dissatisfaction on adolescent body dissatisfaction, weight and shape concern, and pressure to lose weight and dieting in girls.

"In contrast, in boys the effect of body dissatisfaction on later eating disorder outcomes was seen mainly in interaction with BMI. Boys with high BMI and high childhood body dissatisfaction had higher levels of eating disorder cognitions and behaviours, but there was no association with childhood body dissatisfaction among leaner boys."

They added that, "Maternal history of anorexia and/or bulimia nervosa was predictive of high levels of body dissatisfaction and weight and shape concern in girls, and dieting in boys. The effect was more pronounced for children of women who reported both anorexia and bulimia over their lifetime (up to child age seven years)." 

Conclusion

This population-based prospective cohort study showed body dissatisfaction, weight and shape concern, and pressure to lose weight were all significantly higher in girls compared with boys.

The study reported these concerns about body image were all significantly higher in girls compared with boys. This predicted eating disorder in girls at age 14. 

This study has several strengths and limitations. One of the biggest strengths is its size. It had a large population size, which is said to be representative of the overall UK population. This allowed a clear identification of gender-specific patterns. It also assessed various early risk factors in childhood before the onset of the eating disorder behaviours.

However, though the study demonstrates associations, it does not prove causation. Various health, lifestyle and personal factors may be involved in the development of an eating disorder, not all of which have been assessed here.

It is difficult to identify which factor or combination of factors could have been directly involved in the development of an eating disorder.

This is particularly relevant given that assessments on eating disorders or the child's body image and self-esteem are limited to the scope of the few questions used on the assessment questionnaires. These may not always give a reliable indication of how the child or adolescent may feel or what factors have contributed to this.

Another limitation is that despite the use of a large representative cohort, the study is not representative of all people – only 59% took part in the assessment at age 14. Assessment of the whole cohort may have given different results.

It is important to cultivate healthy eating and exercise habits from an early age, and children should be educated about the harmful effects of dieting and binge eating.

If you're concerned about your or your child's weight or body shape, you should see your GP or a dietitian before making any sudden changes to your diet.

Read more advice for parents on eating disorders.

Links To The Headlines

Basis for eating disorders found in children as young as eight. The Guardian, July 23 2015

Childhood anxiousness about appearance can lead to eating disorders in later life, study finds. The Independent, July 23 2015

Links To Science

Micali N, De Stavola D, Ploubidis G, et al. Adolescent eating disorder behaviours and cognitions: gender-specific effects of child, maternal and family risk factors. The British Journal of Psychiatry. Published online July 23 2015

Categories: NHS Choices

Sugary drinks linked to 8,000 new UK diabetes cases a year

Wed, 22/07/2015 - 13:00

"Are sugary drinks causing 8,000 cases of diabetes every year?," the Daily Mirror asks, as a new study estimates they could cause thousands of type 2 diabetes cases in the UK, and millions in the US.

Researchers pooled the results of previous studies to estimate the public health impact of type 2 diabetes associated with sugary drinks consumption, as well as artificially sweetened drinks and fruit juice.

Researchers found that consumption of sugar-sweetened drinks may be linked to 1.8 million cases of type 2 diabetes in the US and 79,000 in the UK over 10 years. They also adjusted their results to take account of body fat (adiposity) and their results suggest that people of a healthy weight may still be vulnerable.

Artificially sweetened drinks and fruit juice also showed a positive association; however, there is thought to be bias associated with this outcome.

As the researchers themselves make clear, this type of study is unable to prove cause and effect.

government report from July 2015 has recommended that sugar should make up no more than 5% of a person’s calorie intake. Therefore, cutting out sugary drinks entirely could be a good way of doing this.

 

Where did the story come from?

The study was carried out by researchers from the University of Cambridge, University of Eastern Finland, Tenri Hospital and Kyoto University in Japan, and Harvard T H Chan School of Public Health in Boston. The study was funded by the Medical Research Council Epidemiology Unit Core Support and an American Heart Association postdoctoral fellowship grant.

The study was published in the peer-reviewed medical journal BMJ on an open-access basis, so is free to read online or download as a PDF.

This study has been widely reported in the UK media. The Guardian and BBC News highlight the fact that slim people may also be vulnerable to the potential harms of sugary drinks.

The Daily Telegraph, the Daily Mirror, Sky News and the Mail Online chose to focus on the potential public health impact estimated in the report: 79,000 new cases of type 2 diabetes in the UK over the course of 10 years and a whopping 1.8 million new cases in the US during the same period.

 

What kind of research was this?

This was a systematic review and meta-analysis assessing consumption of sugar and artificially sweetened drinks, and incidence of type 2 diabetes.

This type of study is useful in combining the results of smaller trials to draw firmer conclusions; however, the strength of the findings depends on the quality of included trials.

The information gathered was used to produce an estimate of the population attributable fraction (PAF) of sugary drink consumption on the incidence of type 2 diabetes.

A PAF is a measure used by epidemiologists to estimate the effect of a risk factor (in this case, sugary drink consumption) on the incidence of disease (in this case, type 2 diabetes) in groups of people.

The assessment of PAFs is a standard way that public health professionals and policymakers estimate the impact of individual factors on an outcome. This information is used to identify how burden of disease can be reduced.

 

What did the research involve?

This study searched PubMed, Embase, Ovid and Web of Knowledge for prospective studies of adults without diabetes at the start of the study, published until February 2014. Data was synthesised using meta-analysis and survey analysis for the PAF associated with the consumption of sugar-sweetened drinks. Data was extracted from selected studies, including:

  • baseline personal information (e.g. body mass index)
  • duration of follow-up
  • exclusion criteria
  • sample size
  • loss to follow-up
  • assessments of beverage consumption
  • incidence of type 2 diabetes
  • types of beverage consumed

Main exposures assessed were:

  • sugar-sweetened drinks, which were any sweetened drink, including sugar-sweetened fruit juice, that are not presented as diet or non-caloric
  • artificially sweetened drinks, including low-caloric soft drinks
  • fruit juice, either 100% fruit juice, or fruit juice assessed separately from fruit drinks

An estimation of PAF was then calculated. The confounding effect of body fat (adiposity) was adjusted for.

 

What were the basic results?

The study included 17 cohorts, comprising 38,253 cases of type 2 diabetes.

National surveys in the US from 2009-10 and the UK from 2008-12 were used to determine the PAFs. This consisted of a sample of 4,729 US adults and 1,932 UK adults over 20 years without prevalent diabetes, representing 189.1 million US adults and 44.7 million UK adults.

Meta-analysis found a link between higher consumption of sugar-sweetened drinks and a greater incidence of type 2 diabetes. One drink per day was associated with an 18% greater incidence in type 2 diabetes before adjusting for body fat, and 13% after adjustment. Similarly, artificially sweetened drinks showed an association with a 25% increase in incidence per one drink per day before adjustment and 8% after; for fruit juice, it was 5% and 7% after adjustment.

The consumption of sugar-sweetened drinks occurred in 54.4% of people in the US and 49.4% in the UK.

If the assumption is made that sugar-sweetened drinks are the cause of type 2 diabetes, independent of obesity status, this would result in 1.8 million cases of type 2 diabetes in 10 years in the US and 79,000 cases in the UK.  The findings also showed that young adults and men have greater numbers of type 2 diabetes due to sugar-sweetened drinks than older adults and women.

 

How did the researchers interpret the results?

The researchers conclude that, "Habitual consumption of sugar sweetened drinks was associated with a greater incidence of type 2 diabetes, independently of adiposity. Although artificially sweetened drinks and fruit juice also showed positive associations with incidence of type 2 diabetes, the findings were likely to involve bias. None the less, both artificially sweetened drinks and fruit juice were unlikely to be healthy alternatives to sugar sweetened drinks for the prevention of type 2 diabetes."

 

Conclusion

This study is a systematic review and meta-analysis that aimed to investigate the associations between consumption of sugar-sweetened drinks, artificially sweetened drinks, and fruit juice with type 2 diabetes, and to estimate the PAF for type 2 diabetes in the UK and US.

Regular consumption of sugar-sweetened drinks was associated with increased incidence of type 2 diabetes.

Artificially sweetened drinks and fruit juice also showed a positive association; however, there is thought to be confounding and publication bias associated with these outcomes.

Consumption of sugar-sweetened drinks may be linked to 1.8 million cases of type 2 diabetes in the US and 79,000 in the UK over 10 years, if we assume causality. However, this study did not prove cause and effect.

Diabetes is a growing problem, with around 3.2 million people aged 16 or over diagnosed with diabetes in England in 2013, and 630,000 people who have not been diagnosed. This is expected to increase. The rise in type 2 diabetes is mostly down to:

  • increasing levels of obesity
  • lack of exercise
  • increase in unhealthy diets
  • an ageing population

Preventative measures against type 2 diabetes can be taken, such as being more active, losing weight and eating more healthily.

Recent recommendations from the Scientific Advisory Committee on Nutrition (SACN) state that free sugars should not exceed 5% of our total dietary energy intake. This applies to all age groups from 2 years upwards. This means

  • no more than 19g a day of free sugars for children aged 4 to 6
  • no more than 24g a day for children aged 7 to 10
  • no more than 30g a day for children aged 11 or more and adults

No specific recommendations are made for children under the age of 2, because of an absence of information. However, from about 6 months of age, a gradual change to a more diverse diet that includes more wholegrains, pulses, fruit and vegetables is encouraged.

Sugary drinks can make up a large proportion of sugar intake and these should be consumed in moderation or, ideally, not at all. As always, maintaining a healthy weight, eating a balanced diet, moderating your alcohol consumption and taking regular exercise will reduce the risk of a range of chronic diseases. 

Links To The Headlines

Are sugary drinks causing 8,000 cases of diabetes every year? Daily Mirror, July 22 2015

Sugary drinks may cause type 2 diabetes regardless of size, research says. The Guardian, July 22 2015

Sugary drinks 'harmful even for slim people'. BBC News, July 22 2015

Sugary drinks behind 8,000 diabetes cases a year. The Daily Telegraph, July 22 2015

Sugary drinks linked to 8,000 type 2 diabetes cases each year: People who consume sweetened beverages every day increase their risk of the condition by 20%. Mail Online, July 22 2015

Sugary Drinks May Cause 8,000 Diabetes Cases. Sky News, July 22 2015

Links To Science

Imamura F, O’Connor L, Ye Z, et al. Consumption of sugar sweetened beverages, artificially sweetened beverages, and fruit juice and incidence of type 2 diabetes: systematic review, meta-analysis, and estimation of population attributable fraction. BMJ. Published online July 21 2015

Categories: NHS Choices

Night shifts 'linked to increased breast cancer risk'

Tue, 21/07/2015 - 11:00

"Irregular sleeping patterns have been 'unequivocally' shown to lead to [breast] cancer in tests on mice, a study suggests," BBC News reports. Scientists are concerned a similar effect may occur in women working night shifts.

This study looked at mice genetically modified to develop breast cancer. They were exposed to either a normal cycle of 12 hours of light and 12 hours of darkness or an inverted cycle. It found mice in the inverted group gained more weight and developed breast cancer sooner.

These findings appear to support previous research suggesting a link between night-shift work and breast cancer, which we discussed in 2012 and 2013.

Further human research will be required to determine if shift working does increase the risk and what measures can be taken to minimise this.

The researchers go as far as recommending that women with a known predisposition to breast cancer (such as having genetic mutations linked to breast cancer) should avoid shift work. But, obviously, not everyone has the luxury of picking and choosing what hours they work.

If you work night shifts, you can offset your risk of breast cancer and other cancers by quitting smoking if you smoke, maintaining a healthy weight, eating a healthy, balanced diet, moderating your consumption of alcohol and taking regular exercise

Where did the story come from?

The study was carried out by researchers from the National Institute for Public Health and the Environment (RIVM), Erasmus University Medical Center and Leiden University Medical Center, all in the Netherlands, and Ludwig-Maximilian University in Germany.

Funding was provided by the RIVM Strategic Programme and the Dutch Ministry of Social Affairs and Employment.

It was published in the peer-reviewed medical journal Current Biology on an open access basis, so it is free to read online or download as a PDF.

The BBC's reporting of the study was accurate and made it very clear at the start of the story that the research involved mice, so the results may not necessarily apply to humans.  

What kind of research was this?

This laboratory research assessed the effects of alternating light cycles in mice. This involved conducting two related studies – a randomised longitudinal study and a cross-sectional study – to assess breast cancer risk with alternating light cycles.

Findings from animal studies are useful for making discoveries to be investigated further in humans.  

What did the research involve?

This study aimed to investigate the causal links between chronic circadian rhythm disturbance (CCRD) and increased cancer risk. CCRD is a term used to describe persistent disruption of the body clock – the normal sleep-wake cycle. 

Breast cancer-prone mice were placed in a cycle of 12 hours of light and 12 hours of dark. At the end of every week, the light or dark phase was extended to 24 hours to invert the light-dark cycle.

Two studies were performed on the mice, controlling for other possible factors contributing to cancer risk:

  • all mice were melatonin deficient
  • neither group was exposed to sunlight
  • there was no vitamin D difference between groups

The only other possible difference between the groups was the timing of food intake, which may be disruptive to metabolism.

Longitudinal study

When the mice reached eight weeks old they were randomly assigned to remain under a normal 12:12-hour light-dark cycle or undergo a weekly alternating 12:12-hour light-dark cycle. Measurements of body weight and tumour-free survival were taken.

Cross-sectional study

Mice who did not take part in the longitudinal study were analysed further in a cross-sectional study. These mice stayed under the light-dark cycle or weekly light-dark inversion, representing circadian rhythm disturbance. After 18 cycles, blood and tissue samples were collected for analysis. 

What were the basic results?

In the longitudinal study, mice exposed to weekly light-dark inversions saw a larger increase in body weight compared with those kept in the normal light-dark conditions.

This was not the result of food intake as a significantly smaller amount of food was consumed by mice in the inversion group. This effect could be seen at six weeks, but it only became significant at week 24.

There was no significant difference in body weight gain in the cross-sectional part of the study, perhaps because there were fewer light-dark inversions.

Mice exposed to the weekly inversions showed a decrease in tumour suppression. This is carried out by certain genes that try to prevent normal cells turning cancerous.

The time taken to breast tumour development was reduced by 17% in the inversion mice compared with the control mice, at 42.6 weeks compared with 50.3 weeks.

The cross-sectional study indicated the circadian rhythm was still disrupted seven days after the light-dark pattern was switched. 

How did the researchers interpret the results?

The researchers concluded that, "Animals exposed to the weekly light-dark inversions showed a decrease in tumour suppression. In addition, these animals showed an increase in body weight.

"Importantly, this study provides the first experimental proof that CRD increases breast cancer development." 

Conclusion

This study in mice appears to support previous research suggesting a link between night-shift work and breast cancer. It looked at an inverted pattern of light and dark to assess whether this is linked to greater risk.

The researchers found mice exposed to weekly light-dark inversions saw a larger increase in body weight and quicker tumour development.

One limitation with this study is it is an animal study, which reduces the generalisability of findings. However, as there are a number of studies that have drawn similar conclusions – some in humans – these findings do add to the research in this area.

Shift working can disturb what is known as the circadian rhythm – the internal body clock. This can disrupt the normal workings of a hormone called melatonin and lead to poor sleep and chronic fatigue.

Rotating shift work and a persistent lack of quality sleep can also disrupt the production of insulin, which may increase the risk of someone developing type 2 diabetes. It has also been linked to a range of chronic conditions, such as obesity, depression, diabetes and heart disease.

The Health and Safety Executive has some useful and practical advice for people who work night shifts:

  • take extra care if you drive to and from work as your concentration may be impaired – if possible, it may be a better idea to use public transport
  • identify a suitable sleep schedule of at least seven hours a day – you may find it useful to keep a diary to assess what sleep times suit you best
  • try to create an environment that promotes good sleep – for example, heavy curtains or an eye mask may help you sleep during the day
  • make changes to your diet to improve alertness and digestion – smaller healthy snacks during your shift may be a better idea than one big meal
  • limit your use of stimulants such as caffeine or energy drinks, as well as sedatives such as alcohol – while they may bring short-term benefits, they are unlikely to help in the long term
  • try to get regular exercise of at least 30 minutes a day

If these findings are correct and shift working does increase breast cancer risk, it is even more important to modify other lifestyle factors known to increase the risk of several types of cancer.

These include quitting smoking if you smoke, maintaining a healthy weight, eating a healthy, balanced diet, moderating your consumption of alcohol and taking regular exercise.

Links To The Headlines

Poor sleeping patterns link to cancer. BBC News, July 21 2015

Links To Science

Van Dycke KCG, Rodenburg W, van Oostrom CTM, et al. Chronically Alternating Light Cycles Increase Breast Cancer Risk in Mice. Current Biology. Published online July 20 2015

Categories: NHS Choices

Study finds obese people may struggle to reach a healthy weight

Mon, 20/07/2015 - 14:50

"Obese men have just a '1 in 210' chance of attaining a healthy body weight," The Independent reports. This was the findings of a study that used a GP records database to look at body mass index (BMI) measurements of almost 300,000 people recorded over a 10-year period.

Overall, it found that low proportions of people in the obese categories achieved a normal weight in subsequent measures – only 1 in 210 for men and 1 in 124 for women who had BMIs of 30 to 35, and much lower than that for the higher BMI categories.

However, this should not be interpreted to mean that if you are obese, you should give up trying to lose weight. Moving from "very obese" to a "normal weight" category may not be realistic, particularly in the short term, and achieving steady weight loss may be a better goal. 

Encouragingly, much higher proportions of obese people in this study were able to achieve 5% or more weight loss (around 1 in 5 to 1 in 10 people). Even a modest reduction in BMI can bring important health benefits.

Ultimately, without knowing the wider health and lifestyle circumstances of the individuals in this study, it is not possible to identify what aspects of obesity management may be less effective.

Rather than opting for the latest fad diet, try the NHS weight loss guide: our popular free 12-week diet and exercise plan.

 

Where did the story come from?

The study was carried out by researchers from King’s College London and the London School of Economics and Political Science, and was funded by the UK National Institutes for Health Research.

The study was published in the peer-reviewed American Journal of Public Health, and the article is open-access – meaning it is freely available to read online or download as a PDF.

The media has reported the findings of this research accurately, but it may have been beneficial to discuss some of the wider contextual issues. For example, it may have been helpful to explain what the figures meant, rather than talking of them as "chances" for someone with obesity to lose weight. That is, they were the proportions of people in each category who had attained a normal BMI each year.

The reporting also didn’t make clear that many people included in the study may not have been trying to lose weight, which could change the assessment of how effective weight loss interventions were. 

 

What kind of research was this?

This was a population-based cohort study, which followed a sample of obese men and women for 10 years to look at what proportion managed to achieve a normal body weight.

Obesity and being overweight are global problems, and finding effective ways to tackle them is an important ongoing issue. Obesity can trigger a wide range of complications, such as type 2 diabetes, heart diseasestroke and non-alcoholic fatty liver disease.

This study assessed how often either a 5% reduction in BMI, or attainment of normal BMI, happens in the general UK adult population.

 

What did the research involve?

This study obtained medical records from the UK general practice database, Clinical Practice Research Datalink (CPRD). Over the 10-year period 2004 to 2014, over 2 million adults (aged over 20) had their BMI recorded on three or more occasions.

People were grouped according to their BMI:

  • normal weight: 18.5 to 24.9 kg/m2
  • overweight: 25.0 to 29.9
  • simple obesity: 30.0 to 34.9
  • severe obesity: 35.0 to 35.9
  • morbid obesity: 40.0 to 44.9
  • super obesity: 45.0 or greater

From each category, a random sample of 30,000 people was taken, and they obtained their full medical records. After excluding those who had weight loss surgery (also called bariatric surgery), they had a final sample of 278,982 people. They then analysed changes in their BMI over the study period, from the first recorded measurement, looking for those who attained normal weight or achieved a 5% reduction in weight. This 5% weight loss outcome was chosen because it is a realistic target that is often recommended to people who are obese and trying to lose weight.

 

What were the basic results?

The average age of the people studied was 55 for men and 49 for women. There were larger numbers of obese women than men. For men, there were around 25,000 (19%) with their first BMI measurement in the normal weight category, then around 27,000 (about 21%) in each of the overweight to severe obesity categories, 14,767 (11%) in the morbid obesity category and 6,481 (5%) in the super obesity category. For women, there were 23,640 (16%) in the normal weight category, then 26,000 to 27,000 (around 18%) in each of the overweight to morbid obese categories, and 18,451 (12%) in the super obese group.

When looking at the proportion of people showing no change in their BMI during follow-up, this was greatest in the normal weight category (men 57%, women 59%).

Only 14% of men and 15% of women showed decreases in their BMI category without also showing increases. Around 1 in 5 people in the morbidly and super obese groups showed decreases in their BMI, which was the highest rate seen. More than a third of people overall showed weight cycling – both increases and decreases in BMI. This was also highest in the severely obese category, where around half showed weight cycling.

During the total follow-up period, 1,283 men and 2,245 women who were obese attained a normal BMI. Overall, this represented about 1 in 60 men and 1 in 44 women over the entire period. However, to account for people being followed up for different lengths of time, the researchers calculated these numbers for each weight category for one year of follow-up.

The probability of achieving a normal BMI from each starting BMI category over one year was:

  • simple obesity: 1 in 210 for men and 1 in 124 for women
  • severe obesity: 1 in 701 for men and 1 in 430 for women
  • morbid obesity: 1 in 1,290 for men and 1 in 677 for women
  • super obesity: 1 in 362 for men and 1 in 608 for women 

The probability of achieving a 5% reduction in weight over a year was higher:

  • simple obesity: 1 in 12 for men and 1 in 10 for women
  • severe obesity: 1 in 9 for men and 1 in 9 for women
  • morbid obesity: 1 in 8 for men and 1 in 7 for women
  • super obesity: 1 in 5 for men and 1 in 6 for women 

However, this 5% weight loss was often accompanied by weight cycling and gains of over 5% in weight at other times.

 

How did the researchers interpret the results?

The researchers conclude that, "the probability of attaining normal weight or maintaining weight loss is low". They go on to say that, "obesity treatment frameworks grounded in community-based weight management programs may be ineffective".

 

Conclusion

This research makes use of a general practice database providing just under 10 years of BMI observations for a large, nationally representative UK sample.

It demonstrates that low proportions of people in the obese categories were able to achieve a normal BMI over a year of follow-up, and the common problem of weight cycling. However, there are points to consider when interpreting these results:

  • The probability of obtaining a normal BMI over a year was very low: only 1 in 210 for men and 1 in 124 for women in the "simple obese" category of 30 to 35kg/m2, and much lower than that for the higher categories. However, these particular figures are only the proportions per year, and we don’t know how many people were attempting to lose weight, or how they were trying to do this. Other analyses showed a better picture – for example, about 1 in 5 obese people managed to reduce their BMI by at least 1 point and not increase it during follow-up.
  • Though the people in this study had 3 or more BMI measurements, we don’t know how long after the first measurement they were taken. Despite the study period being 10 years, the BMI measures may have been over the period of only 1 or 2 years. Reaching a normal BMI may not be a realistic goal in the short term, particularly if a person is in the severe to super obese categories. Achieving steady weight loss may be a better goal and, encouragingly, much higher proportions were able to achieve 5% or more weight loss.
  • The researchers conclude that community-based weight management programmes may be ineffective. However, some care must be taken in concluding that weight loss programmes do not work, because this study only has data on BMI changes. We don’t know anything about the wider health problems or lifestyle circumstances of any of these individuals, or know what care they may have been receiving. As such, we are not able to identify what aspects of obesity management may be ineffective or require a change. We can only say that many obese people did not lose weight.
  • Finally, though this study is a nationally representative sample, there are some exclusions that could influence results. The study excluded people who had received weight loss surgery. These people are likely to have achieved weight loss, and would likely have been in the more severe obesity categories. This may mean that these proportions do not give a true indication of the proportions in the severe obese categories who achieve weight loss. Also, as the researchers acknowledge, weight change may be different in the people who had fewer than two BMI measures over the course of the study; a group who were also excluded.

Nevertheless, this study highlights the growing obesity problem and the need for effective strategies to help people lose weight. If you are obese and trying to lose weight, you should not be discouraged by these results. Eating healthily and exercising have health benefits, even if you do not lose weight, and losing even small amounts of weight and keeping it off in the long term is likely to be beneficial.

Links To The Headlines

Obese men have just a '1 in 210' chance of attaining a healthy body weight. The Independent, July 17 2015

Obesity: 'Slim chance' of return to normal weight. BBC News, July 17 2015

Obese patients 'unlikely' to achieve healthy body weight, study finds. Mail Online, July 17 2015

Links To Science

Fildes A, Charlton J, Rudisill C, et al. Probability of an Obese Person Attaining Normal Body Weight: Cohort Study Using Electronic Health Records. American Journal of Public Health. Published online July 16 2015

Categories: NHS Choices

Sugar intake should be drastically reduced, says report

Fri, 17/07/2015 - 16:00

"Sugar intake 'should be halved'," BBC News reports. The headline is prompted by a government report that recommends no more than 5% of our calorie intake should come from "free sugars". The previous recommendation was 10%.

The new advice says children aged 11 or over and adults should consume no more than seven teaspoons of added sugar a day – 30g, equal to less than a single can of Coca-Cola, which contains 39g.

Children should consume much less than that. The report recommends no more than 19g for children aged four to six (around the amount of sugar in a pouch of Capri Sun) and no more than 24g for children aged seven to 10 (around the amount of sugar in a Snickers bar).

The BBC tells us "all age groups in the UK consume twice as much as this limit", so the gulf between what is good for our health and what we actually do is now wider than ever. The main sources of free sugars are sugar-sweetened drinks, cereal, chocolate, sweets, fruit juice and added sugar at the table.

The Mail Online said that, "Hitting [this] new target will mean cutting out almost all fizzy drinks from diet" and that, "Crisps and chocolate bars will need to become [a] once or twice-week luxury".

Experts generally welcomed the new recommendations, considering them evidence-based and balanced. But some cautioned against too much of a focus on sugar, warning fat is also an important source of calories and should not be overlooked.

The government has reportedly accepted the new recommendations, which will be used as part of a wider strategy to tackle obesity.

This report confirms most of us are consuming way too much sugar and it is damaging our health and our kids' health. But it is one thing setting out what people should aspire to eat to be healthy and quite another making it happen.

Read more about practical ways to lower your free sugars to meet the new recommendations.

What is the basis for these reports?

The story follows new recommendations from the Scientific Advisory Committee on Nutrition (SACN).

The SACN advises Public Health England, who run the NHS in England, and other government agencies and departments on nutrition and related health issues.

Dietary carbohydrates, which include sugar and fibre, and their role in health were last considered in reports published in the 1980s and 1990s. Since then considerable new evidence has emerged, SACN says.

In 2008, the Food Standards Agency and the Department of Health asked SACN to provide clarification on the relationship between dietary carbohydrates and health and make public health recommendations. The new report was prepared in response to this request.

Links To The Headlines

Scientific experts: Sugar intake 'should be halved'. BBC News, July 17 2015

Halve the recommended daily amount of sugar in our diets, scientists tell government. ITV News, July 17 2015

Sugar should be no more than 5% of daily calories, say nutrition experts. The Guardian, July 17 2015

Remove sugary drinks from children's diets, health officials say. The Daily Telegraph, July 17 2015

Parents urged to cut sugary drinks out of their children's diets following landmark report. The Independent, July 17 2015

'Eat no more than SEVEN teaspoons of sugar a day': Government advisers tell families to slash intake by HALF (to less than one can of Coke). Daily Mail, July 17 2015

Now just ONE can of fizzy drink contains child's sugar limit - as official recommended daily amount is slashed in half for all. Daily Mirror, July 17 2015

Categories: NHS Choices

Homer Simpson and Peppa Pig 'linked to childhood obesity'

Fri, 17/07/2015 - 12:35

"Peppa Pig and Homer Simpson could be fuelling the child obesity crisis by causing youngsters to eat more," The Daily Telegraph reports after a series of psychological experiments found a link between exposure to overweight characters and overeating unhealthy food.

This series of three studies involved 301 children aged 6 to 14 years. The children were exposed to images of a normal-weight character, a character drawn to be obviously overweight, or a control image of a picture of a mug, as this was a familiar object but unrelated to weight stereotypes.

Researchers found an association between a higher consumption of unhealthy foods and exposure to the overweight image. This is an interesting finding, as it may mean we need to rethink the design of characters used in marketing and cartoons.

The findings may also help policymakers work out how best to target health promotion messages at this important age group to help them potentially make changes for the rest of their lives.

But claims poor old Peppa Pig is fuelling the obesity crisis seem unfair. Tubby cartoon characters such as Porky Pig, Garfield and Fred Flintstone have been around for decades, before childhood obesity was a problem.

Ultimately, preventing childhood obesity is the responsibility of the parents. Find out more about how to help your child maintain a healthy weight

Where did the story come from?

The study was carried out by researchers from the University of Colorado, Colorado State University and Indiana University.

It was funded by a Sterling-Rice Group grant and an Association for Consumer Research Transformative Consumer Research grant.

It was published in the peer-reviewed Journal of Consumer Psychology.

This has been reported accurately, if uncritically, by the Telegraph and the Mail Online.  

What kind of research was this?

This was a series of three randomised controlled trials aiming to understand whether different body weight cartoon characters influence the amount of non-nutritious food children choose and consume.

Randomised controlled trials are the best way of assessing these associations.  

What did the research involve?

The researchers conducted three trials assessing priming in children and their consumption of more indulgent foods.

Studies one and two made use of colour prints of a normal-weight character, an overweight character or a neutral control, in this case a picture of a mug.

Study one

Sixty children with an average age of 12.9 years were recruited and told they were doing a survey about printers. The children were randomly assigned to see a colour print of a normal-weight character, an overweight character or the control.

The children completed a survey that included questions on age, gender, and family printer ownership and usage. They were also required to list the first three thoughts they had upon seeing the print and were asked to rate print clarity.

After the survey was completed they were thanked and told to take some sweets. The number of sweets taken was recorded for each child.

Study two

This study attempted to examine whether children who see an overweight cartoon character together with a healthy-weight character will choose and consume more indulgent foods than children who do not see an overweight character.

Seventy-four children were included in this study, with an average age of 11.7 years. Participants were randomly assigned to one of three groups where they either saw a picture of a normal-weight character, an overweight character, or the normal and overweight characters together. The rest of the study was the same as for study one.

Study three

The health knowledge of younger children was investigated to see if this had an effect on the amount of unhealthy food they consumed after seeing an overweight cartoon character.

In this study, 167 children with an average age of 8.3 years were randomly assigned to see either a normal or overweight cartoon character either before or after they had been asked questions to activate their health knowledge.

The children's health knowledge was activated by asking them to think about things that make you healthy, and to choose the healthiest option of each of six matched pairs presented both as pictures and words.

For example:

  • getting sleep versus watching television
  • fizzy drinks versus milk
  • playing inside versus playing outside

The activated health knowledge group completed the questions at the beginning of the study, while the non-activated health knowledge group completed the questions as the last part of the study.

Children were exposed to either a normal-weight or overweight cartoon character. The picture was turned over before the children were given a bowl of eight mini biscuits and a taste test questionnaire. They were instructed to have at least one biscuit, and taste perception was rated on a five-point scale from "yucky" to "yummy".

After the biscuits were removed, the cartoon character was turned face up on the table. Participants were instructed to make a collage that best showed what they thought the character was like using stickers.  

What were the basic results?

Study one found an average of 3.8 sweets were taken by those exposed to the overweight image – this was more than twice the amount taken in the control group, who took an average of 1.55 sweets, or the normal-weight image group, who took 1.7 sweets.

Study two found children exposed to the overweight image took an average of 3.21 sweets, compared with 1.77 in the normal-weight group. Participants who saw both the normal-weight and overweight prints took an average of 3.29 sweets.

These findings suggest exposure to an overweight cartoon character activates this stereotype, leading to a greater consumption of sweets.

Study three found when health knowledge was activated, the image shown did not have any effect on the number of biscuits eaten. For children where health knowledge was not activated, behaviour was the same as in studies one and two, with the overweight image resulting in an average of 4.23 cookies consumed, compared with 3.23 cookies in the healthy-weight image group.  

How did the researchers interpret the results?

The researchers concluded that, "Results with children from 6 to 14 years old indicate that overweight cartoon character primes can activate the overweight stereotype, leading to relatively high levels of food intake.

"This effect persisted when participants were simultaneously exposed to a normal-weight and an overweight character together, and was successfully moderated by the activation of health knowledge." 

Conclusion

This interesting study assessed the impact of overweight cartoon characters on children's consumption of unhealthy foods. It shows overweight cartoon characters can activate the overweight stereotype, which may result in a higher consumption of unhealthy foods in children. But activating health knowledge seemed to counter the effects.

The main strength of this trial is that the children were randomly assigned to each group, which reduces the risk of bias. However, this study was conducted in a fairly small number of children from one location, reducing the generalisability of these findings.

Also, the study only looked at the consumption of unhealthy foods. It would have been interesting if the researchers had investigated whether consumption was increased on the whole rather than just with unhealthy snacks, perhaps with healthy alternatives.

The overconsumption of unhealthy snacks may result in increased body weight, which is a concern to parents and society. Excess weight can lead to a range of health concerns, so it's vital to find ways to stop this before it happens.

The best way parents can help is to make sure their child eats a healthy diet and gets plenty of exercise, and to only provide sugary snacks as an occasional treat rather than a staple of their diet. Read more about healthy snack alternatives

Links To The Headlines

How Peppa Pig could be making your children fat. The Daily Telegraph, July 14 2014

Are Shrek, Homer Simpson and Porky Pig making children FAT? Overweight cartoon characters encourage young people to gorge on junk food, study warns. Mail Online, July 14 2015

Links To Science

Campbell MC, et al. Kids, cartoons, and cookies: Stereotype priming effects on children's food consumption. Journal of Consumer Psychology. Published June 17 2015

Categories: NHS Choices

Weak link between depression and frequent smartphone use

Thu, 16/07/2015 - 15:30

"Smartphone behaviour 'could diagnose depression' says new scientific study," the Daily Mirror reports. But based on the data presented in the study the paper is reporting on, we would disagree.

The story was prompted by a small US study of adults who agreed to have a freeware app – Purple Robot – installed on their phone. The app tracks phone usage and physical movement via GPS.

Researchers found people who reported depressive symptoms used their phone more often, visited fewer locations, and spent more time at home than the group of people who did not have symptoms of depression.

The results should not be taken too seriously as these two groups of people were not matched, so other factors could have influenced the results (confounders).

A major factor that was not accounted for was whether any of the people involved in the study were employed, the nature of the employment, or whether they were looking after children or caring for someone. This would have had a major impact on their phone use and the amount of time they spent going out to different places.

Other factors commonly taken into account but not included in this study are a history of mental health problems, age, sex and any medical or psychiatric conditions.

In short, this study does not show smartphone use can diagnose depression.  

Where did the story come from?

The study was carried out by researchers from Northwestern University and Michigan State University, and was funded by the US National Institute of Mental Health.

It was published in the peer-reviewed Journal of Medical Internet Research.

The authors do not declare any conflict of interest. They developed an open-source app called Purple Robot, which is designed to collect mobile phone sensor data.

Purple Robot has also been used in studies designed to optimise adherence to treatment regimes for people with HIV, ulcerative colitis and Crohn's disease.

The Mail Online coverage of the story included some inaccuracies, such as saying, "The phone data turned out to be a more reliable way of detecting depression than asking participants questions about how sad they were feeling on a scale of one to 10".

But the scales used were from one to three, and it is not clear how the phone data could be "more reliable" when none of the participants were assessed for symptoms of depression other than their answers to this symptom-scale questionnaire.

The Mail also says that, "Using a phone stops people dealing with difficult feelings" without pointing out this was just the authors' hypothesis and not actually assessed in the study.

Similarly, the Daily Mirror carried a number of quotes from the lead author, such as, "We now have an objective measure of behaviour related to depression", without subjecting these comments to any scrutiny.  

What kind of research was this?

This observational study aimed to see if people who self-reported symptoms of depression were likely to use their mobile phones more than people who did not have symptoms of depression.

It also aimed to see if they were less likely to go out to different places.

This type of study can only show an association and cannot prove cause and effect.

What did the research involve?

Forty adults aged between 19 and 58 were recruited to take part in the study. They were asked to download an app called Purple Robot on to their phone.

This app measured their phone usage and mapped their location using GPS. The participants were asked to keep the phone with them at all times for two weeks.

At the beginning of the study they completed the Patient Health Questionnaire-9 (PHQ-9) to record any self-reported symptoms of depression. This questionnaire asks people to rate nine different symptoms of depression from 0 (not at all) to three (nearly every day). Scores can range from 0 to 27.

This screening questionnaire gives an indication of whether a person is likely to be depressed, but a diagnosis would require further clinical assessment. The scores suggest the following:

  • 5 to 9 – mild depression
  • 10 to 14 – moderate depression
  • 15 to 19 – moderately severe depression
  • 20 or more – severe depression

The researchers split the people into two groups – one group scored less than five on the PHQ-9 and the other group scored five or more. The researchers then analysed the results looking for any associations between depressive symptoms, phone usage and how much a person was out and about.  

What were the basic results?

Data was available for only 28 of the participants, with 14 in each group. The average PHQ-9 score for the depressive group was 9.6, which would be rated as mild.

People with depressive symptoms went out less often and spent more time at home. They also used their phone more often, but the study doesn't report if these participants used their phone for texting, surfing the internet or talking to someone.  

How did the researchers interpret the results?

The researchers concluded mobile phone use could be used to help identify people with depressive symptoms.

They say that, "While these findings must be replicated in a larger study among participants with confirmed clinical symptoms, they suggest that phone sensors offer numerous clinical opportunities, including continuous monitoring of at-risk populations with little patient burden and interventions that can provide just-in-time outreach." 

Conclusion

This small study suggests people who report higher levels of depressive symptoms may use their phone more and go out less.

However, these findings should not be taken too seriously as this study has many limitations, including:

  • a small sample size – data from only nine people in each group was used for the location data
  • there was no attempt to ensure the two groups were matched in terms of any medical illness, age, sex, whether they were employed, or any other potential confounding factors
  • it's not known whether any of the participants in either group had a diagnosis of depression or any other mental illness
  • the analysis relied on the participants keeping their mobile phone with them continuously, which may or may not have actually happened

In short, this study does not show that mobile phone use can diagnose depression. As the researchers point out, a much larger – and, in our opinion, better designed – study would be required to see if a depression app or similar would be a viable idea.

If you are feeling low, it is a good idea to talk to someone or seek professional help. The Samaritans are available 24 hours a day, 365 days a year if you are in distress and can be reached on 08457 90 90 90.

Links To The Headlines

Smartphone behaviour 'could diagnose depression' says new scientific study. Daily Mirror, July 15 2015

How your SMARTPHONE could diagnose you with depression: Using it for 68 minutes a day 'may be a sign of mental illness’. Daily Mail, July 15 2015

Links To Science

Saeb S, Zhang MI, Karr CJ, et al. Mobile Phone Sensor Correlates of Depressive Symptom Severity in Daily-Life Behavior: An Exploratory Study. Journal of Medical Internet Research.

Categories: NHS Choices

Should we worry about the 'flesh-eating killer bug'?

Wed, 15/07/2015 - 10:59

A "terrifying" and "flesh-eating" bug that "kills one in four it infects invasively" is spreading around the world, warns The Daily Telegraph in news that surprisingly didn't make its front page.

So why is everyone in the country not wearing biohazard onesies? Probably because the threat from this kind of infection is extremely low.

The key fact is that while the emm89 strain of group A streptococcus bacteria was reported to kill one in four people it infects invasively, just over a hundred were infected in this way by this strain in 2013.

The case fatality rate reported in this study of 21% (actually closer to one in five than one in four) makes these invasive infections very serious. For comparison, in the latest outbreak of Ebola the case fatality rate was around 50%. Fortunately, it is not common.

In fact, "strep A" bacteria are generally very common and usually harmless or only slightly problematic. They live on our skin and give us sore throats, earache, and the usually self-limiting but very contagious scarlet fever.

The research behind this news brought together data on the increasing prevalence of the emm89 bacteria and genetic changes in the strain over time, and their effects on the bacteria. Researchers were surprised to find its structure was different from other types of invasive bacteria.

Infections are best avoided by maintaining good hygiene, including washing your hands. 

Where did the story come from?

The study was carried out by researchers from Imperial College London and other research centres in the UK.

It was funded by the National Institute for Health Research Biomedical Research Centre and the UK Clinical Research Collaboration.

The study was published in the peer-reviewed scientific journal mBio. This is an open access journal, meaning the study can be accessed online for free.

The news has focused on the spread of these bacteria in the UK and the high death rate in people who have an invasive infection.

But this research doesn't show that the new form of emm89 is any more deadly than other invasive forms of group A streptococcus. In fact, researchers were mainly interested in the genetics of these bacteria, prompted by the new form of emm89 becoming more common.

The Telegraph failed to make it clear that, in general, invasive infections with group A streptococcus are uncommon. There were about 1,500 cases in 2013, and only about 100 caused by emm89. The Telegraph's "terrifying" and "flesh-eating" coverage could therefore be seen as unnecessarily alarmist. 

What kind of research was this?

This laboratory study looked at the DNA of a strain of group A streptococcus bacteria.

Each year, 600 million people worldwide have a group A streptococcus infection. The bacteria are often found on the surface of the skin and in the throat, and can cause minor infections in these areas.

In rare cases, the bacteria go deeper into the body to cause more serious "invasive" infections. This can include pneumonia and the "flesh-eating" skin infection, necrotising fasciitis.

One type, called emm89, has become one of the main group A streptococcal bacteria that causes disease. Over the last 10 years, the researchers have found an increase in invasive disease caused by emm89.

Because the emm89 strain has not been widely studied, researchers wanted to study its genetic makeup and how it has changed over time. They wanted to understand whether these changes might explain why it has become more common. 

What did the research involve?

The researchers used national data on all cases of invasive group A streptococcal disease in England and Wales between 1998 and 2013. They wanted to know how common the emm89 strain was and how many people died from the invasive infection.

The researchers also analysed the DNA of 131 emm89 samples (58 invasive, 73 non-invasive) collected between 2004 and 2009 to see how it had changed.

They used computer analysis to look at how these changes were likely to have arisen over time, and looked at how these changes might impact the biology of the bacteria.

Finally, the researchers investigated how the genetic changes made differences to the properties of the bacteria in a lab. 

What were the basic results? Prevalence of the streptococcus A emm89 strain

The researchers found an increase in the amount of invasive group A streptococcal disease caused by the emm89 group of bacteria in England and Wales between 1998 and 2013.

Between 1999 and 2005 all forms were increasing, but between 2005 and 2009 emm89 was increasing more than other types of group A streptococcus. Emm89 was responsible for 10% of all invasive A streptococcal disease in 2005, and 18% in 2007.

Between 2003 and 2013 about a fifth of people with invasive A streptococcal disease died within 30 days.

Genetic changes in the streptococcus A emm89 strain

The researchers identified genetic changes in the emm89 group over time in the UK. Analysis suggested a group of emm89 bacteria with one particular set of genetic changes had emerged in the 1990s and taken over as the main form of the bacteria over time.

The researchers found this group (or "clade") had changes in two regions of its DNA known to affect how infectious the bacteria are. This included losing the genes that usually make the outer coating of the bacteria.

This was surprising – without these genes, the bacteria cannot produce this coating, which had been thought to be essential for the bacteria to infect cells and stop the immune system destroying them.

The researchers found bacteria from this clade could stick to and grow on a plastic surface in the lab better than other forms of emm89. All the forms survived and multiplied in human blood in the lab similarly well.  

How did the researchers interpret the results?

The researchers concluded that, "The rise of emm89 iGAS in the United Kingdom coincided with the emergence and increased prevalence of a variant acapsular clade that differed from the rest of the emm89 population." 

Conclusion

Unlike in the BBC 4 drama, "Cordon", it's unlikely that the streets will be barricaded because of an outbreak of this deadly infection featured in today's news.

The study behind the headlines looked at genetic changes over time within the emm89 form of group A streptococcus bacteria. It found a new form emerged that has become more common over time, and identified the genetic changes that may have contributed to this rise.

This type of study is useful for researchers to look at how infectious organisms change over time and become more successful. It can help researchers track the spread of different forms of bacteria, and may help us develop ideas about new ways to treat them.

There are some points to note about this study. The researchers observed there was no evidence this new clade caused more severe invasive disease than other strains.

Also, although the papers call this a "flesh-eating bug", many of the infections caused by group A streptococcus are mild. The term "flesh eating" is news-speak for one form of invasive group A streptococcus infection called necrotising fasciitis, which makes up only some of the invasive cases of group A streptococcus disease.

Links To The Headlines

Flesh-eating bug 'kills one-in-four of people it infects in UK'. The Daily Telegraph, July 15 2014

Surge in terrifying new strain of flesh-eating bug across the world: Infection KILLS one in four victims in severe cases. Daily Mail. July 14 2015

Links To Science

Turner CE, et al. Emergence of a New Highly Successful Acapsular Group A Streptococcus Clade of Genotype emm89 in the United Kingdom. mBio. Published July 14 2014

Categories: NHS Choices

Researchers identify protein that spreads cancer

Tue, 14/07/2015 - 13:00

"Scientists have found a way of preventing the spread of cancer from the site of the original tumour," The Independent reports. Targeting proteins called DNA-PKcs could prevent cancer cells moving to other parts of the body. This is known as metastatic cancer and is often fatal.

The research involved mice as well as tissue samples from more than 200 prostate cancer patients. Researchers found mice treated with an inhibitor to block DNA-PKcs had reduced cancer spread compared with mice that were not treated.

Patients whose prostate cancer tissue samples showed higher DNA-PKcs levels were more likely to have had cancer progression (metastasis). As yet we do not know if a DNA-PKcs inhibitor would have the same outcome in humans as it did in mice.

This research furthers our knowledge about the biology of cancer progression and has identified another possible way to tackle the spread of cancer. Further investigation in humans would be required to confirm whether these findings are of use for improving outcomes for prostate cancer patients.  

Where did the story come from?

The study was carried out by researchers from Thomas Jefferson University, the University of Michigan, Cleveland Clinic, the University of California, Los Angeles (UCLA), the Mayo Clinic, Columbia University Medical Centre, and GenomeDx Biosciences.

It was funded by the Prostate Cancer Foundation (PCF), PCF/Movember and Evans Foundation, PA CURE, the US Department of Defense, UCLA, the National Cancer Institute, and the National Institutes of Health.

The study was published in the peer-reviewed journal Cancer Cell.

This research has been reported in the media as a breakthrough – the Daily Express goes as far as talking about a possible "cure". However, while certainly promising, the research is at an early stage. Crucially, we do not know whether these findings will result in new treatments in humans.  

What kind of research was this?

This laboratory and animal study in mice looked at whether the protein DNA-PKcs is linked to cancer progression. This type of animal study is used to understand the biology of human disease better.

While there are a lot of similarities in the biology of different species, there are some key differences. This means that while results do give an indication of what is likely to happen in humans, we cannot be certain that any findings would be exactly the same.

Researchers looked at some prostate cancer tissue samples to see if their findings looked like they might apply to people, but the human research is at an early stage. 

What did the research involve?

The researchers first studied DNA-PKcs in cells in the lab to look at what it does in the cell. It was believed to aid the spread of cancer cells.

They then used mice injected with human prostate cancer cells to investigate whether it is possible to stop cancer spread by targeting the DNA-PKcs protein.

Mice were either treated with an inhibitor that blocks the DNA-PKcs protein or an inactive control treatment. The size of their tumours was monitored by live imaging.

After 31 days three mice were selected from the control arm and switched to receive the DNA-PKcs inhibitor to investigate the impact. Three mice were also selected from the protein inhibitor group and stopped receiving this treatment.

The researchers went on to analyse cancer tissue samples from 232 patients with prostate cancer, and measured the amount of DNA-PKcs the cells contained. The researchers looked at how their DNA-PKcs levels related to their outcomes. 

What were the basic results?

The laboratory tests showed the DNA-PKcs protein was involved in controlling the activity of genes cancer cells need to move and spread. The researchers also found blocking DNA-PKcs reduced the spread of cancer in mice.

Mice who crossed over from the control arm to the protein inhibitor did not show a reduction in tumour size. This implies the DNA-PKcs inhibitor blocked the spread of cancer rather than suppressing tumour growth.

When mice stopped receiving the DNA-PKcs inhibitor, their cancer spread. Mice who stayed on the DNA-PKcs inhibitor and did not cross over were found to have less cancer spread than those who stayed in the control arm.

The patient samples showed men with higher DNA-PKcs levels were more likely to have had prostate cancer progression and to have died. 

How did the researchers interpret the results?

The researchers concluded they have identified DNA-PKcs as a protein that drives prostate cancer progression and spread.

Higher levels of DNA-PKcs in prostate cancer tissue were an independent predictor of metastasis, recurrence and poor survival. Researchers hope this discovery will pave the way for new drug treatments. 

Conclusion

This lab study in mice found a protein called DNA-PKcs is involved in the spread of cancer cells, and assessed whether it is possible to stop this spread by targeting the protein.

It demonstrated that mice with human prostate cancer cells treated with an inhibitor to block the protein had reduced cancer spread compared with those who were not treated.

Analysis of patient prostate cancer samples showed higher DNA-PKcs levels were linked to a greater risk of cancer progression. This suggests the protein may be playing a similar role in humans, and researchers will want to go on to see if DNA-PKcs inhibitors could be used as a new treatment to stop the spread of cancer.

This protein is involved in the spread of cancer but does not appear to be involved in cancer growth, so any new drugs blocking it would also need to be used alongside other drugs. It's also not yet clear whether the findings only apply to prostate cancer cells.

While this research seems to show promise, the findings on the DNA-PKcs inhibitors were in mice and therefore may not be applicable to humans. Headlines reporting this as a cancer "breakthrough" should be taken with caution.

Researchers will need to determine whether these inhibitors seem safe and effective enough in animals before they could be tested in humans. Once this is done, a randomised trial in humans would be required before we know its effects.   

Links To The Headlines

Scientists discover way of targeting 'lynchpin' molecule to prevent the spread of cancer. The Independent, July 13 2015

Cancer breakthrough as scientists discover 'master switch' that causes the disease to spread, paving the way for new life-saving treatments. Mail Online, July 13 2015

New drug to beat cancer: Breakthrough as scientists find key to stopping disease. Daily Express, July 14 2015

Links To Science

Goodwin JF, Kothari V, Drake JM, et al. DNA-PKcs-Mediated Transcriptional Regulation Drives Prostate Cancer Progression and Metastasis (PDF, 4.43Mb). Cancer Cell. Published online July 13 2015

Categories: NHS Choices

No proof tea is the 'elixir of life'

Mon, 13/07/2015 - 14:30

"Is the elixir of life as simple as two cups of tea?," the Mail Online asks, prompted by a study looking at whether tea drinking is associated with a longer life expectancy in women.

This study included more than a thousand older women with an average age of 80. The women completed food and drink questionnaires, and the data from this was put into special databases to estimate their flavonoid intake.

Flavonoids are plant compounds found in various foods and drinks, including tea, chocolate and wine. They are said to have an antioxidant effect by helping prevent cell damage.

The researchers looked at how flavonoid intake was linked to the women's risk of death from any cause over the next five years.

They found those with the highest intake had a reduced risk of death compared with those with the lowest. In this group of older women, black tea contributed the most to total flavonoid intake.

However, although the study did find a link, this does not prove that tea or flavonoids are the single direct cause of reduced mortality. Various unmeasured health and lifestyle factors (confounders) could have influenced the results.

There are also possible inaccuracies in the estimation of flavonoid intake, and the results of this older group of Australian women cannot be applied to everyone.

Overall, this study does add to the body of research assessing flavonoids, but provides no proof that the compound – or tea specifically – reduces mortality in older women.

Where did the story come from?

The study was carried out by researchers from the University of Western Australia.

It was funded by Kidney Health Australia, Healthway Health Promotion Foundation of Western Australia, Sir Charles Gairdner Hospital Research Advisory Committee, and project grants from the National Health and Medical Research Council of Australia.

It was published in the peer-reviewed American Journal of Clinical Nutrition.

The Mail Online's coverage hailing tea the "elixir of life" has not taken into account the important limitations of this research. 

What kind of research was this?

This prospective cohort study followed a group of older women over the course of five years to explore any links between flavonoid intake and overall mortality.

Flavonoids are plant compounds thought to have various potential health benefits, including effects on the cardiovascular system and glucose metabolism. Particularly rich sources include tea, chocolate, fruit and red wine.

Though previous research has investigated the link between flavonoids and particular health outcomes such as cardiovascular disease and cancer, there is said to have been little research investigating all-cause mortality.

Cohort studies such as this can demonstrate associations but cannot prove cause and effect, as other factors could be involved.  

What did the research involve?

This study included 1,136 postmenopausal women (aged over 75) taking part in the Calcium Intake Fracture Outcome Age Related Extension Study that started in 2003. This was an extension of a randomised controlled trial of calcium supplements to prevent fractures.

The study included 1,063 women who completed food questionnaires in 2003. These questionnaires included questions on average tea and coffee consumption over the past 12 months.

The study then followed up all-cause mortality over the following five years to 2008, linking the women to database registries. These recorded cardiovascular and cancer events using valid medical codes, and deaths were also identified in the mortality register.

The researchers used two different databases on the flavonoid composition of different foods and drinks so they could estimate flavonoid intake.

They then looked at the link between all-cause mortality and flavonoid intake. They took into account potential confounders recorded at the start of the study.

These included existing cardiovascular disease and cancer recorded in the registries, age, body mass index (BMI), self-reported smoking status, alcohol consumption, fruit and vegetable intake, and physical activity. 

What were the basic results?

Over the five years of follow-up, there were 129 deaths (12% of women). Average daily flavonoid intake was 674-696mg a day, depending on which of the two databases was used to estimate flavonoids.

Higher flavonoid intake was associated with a reduced risk of all-cause mortality. Compared with women with the lowest intake (less than 525 or 547mg a day), those with the highest intake (above 788 or 813mg a day) had a 62-64% significantly reduced risk of mortality – again, depending on which database was used to estimate flavonoids.

The researchers found similar results when looking specifically by cause of death, whether cardiovascular or cancer.

When the researchers looked specifically at flavonoids, black tea appeared to be the major dietary contributor. Tea accounted for between 59% and 82% of the total flavonoid intake.  

How did the researchers interpret the results?

The researchers said that, "Using the most comprehensive flavonoid databases, we provide evidence that high consumption of flavonoids is associated with reduced risk of mortality in older women. The benefits of flavonoids may extend to the [disease cause] of cancer and cardiovascular disease." 

Conclusion

Flavonoid plant compounds have been researched extensively, with studies exploring their possible health benefits.

In this research, there is an association between higher flavonoid intake and a reduced risk of death from any cause over five years in a cohort of older women.

However, this study provides no proof that drinking tea will help you live longer. There are several important points to bear in mind:

  • The design of this study cannot prove cause and effect. Though it has adjusted for various potential health and lifestyle confounders, it is unlikely to have taken all of them into account. It is therefore not possible to say that flavonoids are the single direct cause of reduced mortality.
  • This is a very specific population group: postmenopausal women with an average age of 80 who were recruited to a trial investigating calcium supplements to prevent fractures. They therefore may not be representative of all older women – for example, the women in this trial were of quite high socioeconomic status. Their results can certainly not be applied to women as a whole, or men.
  • Foods and drinks were assessed by food frequency questionnaire. Although these may be validated ways of assessing intake, they are still subject to inaccuracy. For example, people may not be able to give a reliable indication of their tea consumption over the past year.
  • This information on foods and drinks was put into two different databases to estimate flavonoid intake. As the results showed, the total intake amounts, or the risk reductions, varied depending on which of the two databases were used. This means these may not be completely accurate estimates of flavonoid intake.
  • The media linked these findings to tea, as black tea was the major source of flavonoids, though the main risk analyses were not solely based on flavonoid intake from tea. The researchers say an intake of about 350mg is equivalent to approximately two cups of tea, so the highest intakes of 788 or 813mg a day would be equivalent to more than four cups of tea.

Overall, this study adds to the body of research assessing the benefits of flavonoids, but provides no proof that they – or tea specifically – reduce mortality in older women.

Read more about health advice for women aged 60 and above.

Links To The Headlines

Is the elixir of life as simple as two cups of tea? Daily cuppas 'can dramatically increase longevity in older women'. Mail Online, July 10 2015

Drinking daily cups of tea makes women live longer, a new study finds. Metro. July 11 2015

Links To Science

Levy  KL, Hodgson JM, Croft KD, et al. Flavonoid intake and all-cause mortality. The American Journal of Clinical Nutrition. Published online April 1 2015

Categories: NHS Choices

Are teens confused about their size and weight?

Thu, 09/07/2015 - 18:00

"Third of overweight teenagers think they are right size, study shows," The Guardian says in one of many headlines on widely covered UK research.

The research, which looked into English 13-15-year-olds' understanding of their own weight, led the Mail Online to refer unkindly to "generation fat-blind".

The large study demonstrated that while most normal-weight adolescents correctly see themselves as about the right weight, a large number of overweight or obese adolescents wrongly thought they were about the right weight or too light.

Parents probably ought to refrain from a "told you so" attitude to this news, as so-called fat shaming is not considered a great way to help anyone lose weight.

Helping a teen to understand that familiar media images of overweight and obese people don't necessarily give the full picture, and that addressing the problem can improve the quality and length of their life, may be more successful.

The findings may also help policymakers work out how best to target health promotion messages at this important age group and help them potentially make changes for the rest of their lives. 

Where did the story come from?

The study was carried out by researchers from University College London and was funded by Cancer Research UK.

It was published on an open-access basis in the peer-reviewed International Journal of Obesity.

This study was accurately reported by a number of media sources, with a good explanation of its key findings and the risks associated with obesity.

However, there was a general lack of information about the limitations of this study. The Mail's headline use of the term "fat-blind" may be seen as pejorative and misleading, especially when we do not necessarily understand all the reasons for the research findings. 

What kind of research was this?

This study analysed data from the Health Survey for England looking at adolescents' perception of their weight.

Looking at this data is a good way to understand adolescents' weight perceptions because measurements were taken professionally and weight perception questions were self-reported in the survey.

However, this type of study can have chunks of missing data, particularly where people declined to be weighed, which may have biased the results. 

What did the research involve?

The researchers used data for 4,979 teens aged 13 to 15. The data was taken from the results of the Health Survey for England between 2005 and 2012.

This annual survey presents a representative sample of the general population of England. It surveys adults and up to two children under 16 (selected at random in families with three or more eligible children).

Researchers weighed and measured the teens at home, and then calculated their body mass index (BMI). Weight status was defined according to the International Obesity Taskforce criteria, which classifies BMI values according to age and sex as:

  • thin (underweight)
  • normal weight
  • overweight
  • obese

The 13-15-year-olds were also asked: "Given your age and height, would you say that you are about the right weight, too heavy, or too light?".

The researchers also included age, sex, ethnicity and the socioeconomic status of the teens in their analyses. 

What were the basic results?

The data showed nearly three-quarters (73%) of adolescents in the study had a BMI placing them in the normal weight range, but 20% were overweight and 7% were obese.

Normal-weight adolescents generally felt they were the correct weight (83%), with just 7% who thought they were too heavy, while 10% thought they were too light.

More girls (11%) considered themselves too heavy than boys (4%). Girls (6%) were also less likely to consider themselves too light than boys (13%).

Overestimation was more likely among those on the heavier end of the normal-weight group (10%) than the lighter end (2%).

About 60% of the overweight/obese group felt they were too heavy, 39% thought they were about the right weight, and 0.4% felt they were too light.

Again, girls (68%) who were overweight or obese were more likely to think so than boys (53%).

Girls (32%) were also less likely than boys (47%) to think they were the right weight or too light. Overweight adolescents were much more likely to underestimate their weight (52%) than those who were obese (7%).

The researchers excluded adolescents who were underweight from the analysis as this group consisted of 248 people, which they say was too small to calculate meaningful results. 

How did the researchers interpret the results?

The researchers concluded that, "Overestimation of body weight among normal-weight adolescents is relatively uncommon; potentially a cause for celebration.

"However, almost half of boys and a third of girls with a BMI placing them in the overweight or obese BMI range perceived themselves to be about the right weight.

"Lack of awareness of excess weight among overweight and obese adolescents could be cause for concern." 

Conclusion

This study aimed to see whether UK teenagers' perception of their weight matched up with reality. It demonstrated that most normal-weight adolescents correctly see themselves as about the right weight and they overestimated their weight fairly rarely.

But a large proportion of overweight and obese adolescents thought they were about the right weight or even too light.

This study had a large population size, and analyses were weighted to match key population characteristics.

However, the weight measurements were not available for all adolescents in the survey – this may have represented those who were more concerned about their weight and declined measurement, leading to biased results.

Also, overweight and obese adolescents may not have completed the questionnaires truthfully through embarrassment or fear of the consequences.

Only people aged 13 to 15 were analysed, so further research would need to be carried out in other age groups to target issues associated with weight perception if necessary.

Overweight and underweight teens are a concern to both their parents and society. They are likely to grow into overweight or underweight adults, particularly if they do not see that they are not a healthy weight.

The reasons teenagers don't see themselves as overweight may include the commonly seen images of severely obese individuals in the media used to represent stories about weight issues. These could lead to the impression that only those who have a visibly very high body weight are overweight or obese.

Excess weight can lead to a range of other health concerns, including an increased risk of type two diabetes and certain cancers.

Even if teenagers aren't interested in these long-term health messages, it's vital to find ways to improve their understanding of the implications of their weight. And if they understand, it's vital we're able to give them simple advice on achieving a healthy weight in a way that doesn't make them feel patronised.

Links To The Headlines

Third of overweight teenagers think they are right size, study shows. The Guardian, July 9 2015

Generation 'fat-blind': More than a third of obese teenagers think their weight is 'about right', study warns. Daily Mail, July 9 2015

Overweight teens 'do not see themselves as too heavy'. BBC News, July 9 2015

Links To Science

Jackson SE, et al. Weight perceptions in a population sample of English adolescents: cause for celebration or concern? International Journal of Obesity. Published July 9 2015

Categories: NHS Choices

Online symptom checkers' reliability assessed

Thu, 09/07/2015 - 13:00

"The danger of an online diagnosis: Millions of emergencies are MISSED through symptom checker websites," the Mail Online reports. American researchers have assessed the accuracy and reliability of 23 symptom checkers, including the NHS Choices symptom checker.

The researchers were looking at both accuracy of diagnosis and triage. Triage is the process of determining the severity of a condition.

They did this by using a series of symptoms and medical history known to be associated with specific conditions. These types of combination are known as clinical vignettes.

The NHS Choices symptom checker doesn’t offer a diagnosis – it only provides triage advice.

Researchers found that the NHS Choices symptom checker correctly identified emergency and urgent conditions in 87% of cases. But it also incorrectly triaged non-emergency or non-urgent conditions in 80% of cases, which theoretically would result in an unneeded visit to A&E or a call for an ambulance.

While symptom checkers are far from perfect, they are better than just leaving people "Googling" their symptoms, which is estimated to have a 64% success rate in identifying emergency and urgent cases.  

Where did the story come from?

The study was carried out by researchers from Harvard Medical School, Brigham and Women’s Hospital, Boston Children’s Hospital and Beth Israel Deaconess Medical Center, all in Boston. It was funded by the US National Institutes of Health.

Researchers involved in this study say they have not been, nor plan to be, involved in the development, evaluation, promotion, or any facet of a Harvard Medical School-related symptom checker and they had no support from any organisation for the submitted work. This includes no financial relationships with any organisations that might have an interest in the submitted work in the previous three years, or other relationships or activities that could appear to have influenced the submitted work.

In the interests of transparency, we should also point out the Behind the Headlines editorial team is employed by the Health & Social Care Information Centre, which is the same NHS organisation that runs the NHS Choices symptom checker.

The study was published in the peer-reviewed British Medical Journal on an open-access basis, so the study is free to read online or download as a PDF.

It was reported by the Mail Online website in the UK. Overall, the Mail reported the story accurately, but the limitations of the study were not fully explained. Its headline "Millions of emergencies are MISSED through symptom checker websites, study warns" is untrue. The study provides no estimate of how many emergency cases were misdiagnosed by symptom checkers around the world.

 

What kind of research was this?

This was an audit study that aimed to assess the diagnostic and triage accuracy of online symptom checkers (tools that use computer algorithms to help patients with self-diagnosis or self-triage). Triage is the process of determining the priority of patients' treatments, based on the severity of their condition.

With improvements in technology and access to the internet, people are increasingly using the internet to research their health concerns. For example, researchers quote that the NHS Choices website has over 15 million visits per month. That figure was actually based on 2012 data; the figure for 2015 averages around 50 million visits a month.

Although there are many advantages to using symptom checkers, such as providing out-of-hours advice and reducing the burden on GP and A&E departments, they cannot always take the place of face-to-face clinical assessment.

 

What did the research involve?

Researchers searched for online symptom checkers that were in English, free to access, publicly available, and did not focus on a single type of condition.They used terms like "symptom checker" or "medical diagnosis" to find symptom checkers in Google and Google Scholar, and also searched for any relevant apps in the Apple app store and Google Play.

After searching and sifting, they finally included 23 online symptom checkers for further analysis. They categorised symptom checkers by whether they facilitated self-diagnosis, self-triage, or both. They also categorised them according to the type of organisation they were operated by, the maximum number of diagnoses provided and whether they were based on Schmitt or Thompson nurse triage guidelines. These are decision support protocols commonly used in telephone triage for paediatric and adult consultations, respectively.

To evaluate the diagnosis and triage performance of the symptom checkers, they used 45 standardised patient vignettes. They say they used this method to assess the performance of the symptom checkers, because this method is commonly used by physicians and other clinicians on their diagnostic ability and management decisions. These 45 clinical vignettes were further divided as either "common" or "uncommon" diagnoses. Triage advice was further divided into three groups:

  • Emergency, which included advice to call an ambulance, go to the emergency department, or see a general practitioner immediately.
  • Non-emergency, which included advice to call a general practitioner or primary care provider, see a general practitioner or primary care provider, go to an urgent care facility, go to a specialist, or go to a retail clinic.
  • Self care, which included advice to stay at home or go to a pharmacy.

Each standardised patient vignette was entered into each website or app, and resulting diagnosis and triage advice was recorded.

 

What were the basic results?

The 23 symptom checkers included in this study were based in the UK, US, the Netherlands and Poland. The 45 standardised patient vignettes used to assess the performance of these symptom checkers included 26 common and 19 uncommon diagnoses.

Performance on diagnosis

Overall, the correct diagnosis was listed first 34% of the time. For different levels of triage, the percentage of the correct diagnosis being listed first is below:

  • 24% (95% confidence interval (CI) 19% to 30%) for emergency evaluations
  • 38% (95% CI 32% to 34%) for non-emergency evaluations
  • 40% (95% CI 34% to 47%) for self care evaluations
Performance on triage advice

The included online symptom checkers correctly gave triage advice 57% of the time. For different levels of triage, the percentage of correct advice is below:

  • 80% (95% CI 75% to 86%)  for emergency care evaluations
  • 55% (95% CI 47% to 63%) for non-emergency evaluations 
  • 33% (95% CI 26% to 40%) for self care evaluations

 

How did the researchers interpret the results?

Researchers concluded by saying, "Physicians should be aware that an increasing number of their patients are using new internet-based tools such as symptom checkers and that the diagnosis and triage advice patients receive may often be inaccurate. For patients, our results imply that, in many cases, symptom checkers can give the user a sense of possible diagnoses, but also provide a note of caution, as the tools are frequently wrong and the triage advice overly cautious."

They added, "Symptom checkers may, however, be of value if the alternative is not seeking any advice or simply using an internet search engine. Further evaluations and monitoring of symptom checkers will be important to assess whether they help people learn more and make better decisions about their health."

 

Conclusion

This audit study showed that online symptom checkers sometimes correctly diagnose and advise people according to their symptoms, but they can be inaccurate. Though the appropriate triage advice was only accurate, on average, 57% of the time, the study found this advice erred on the side of caution, advising people to seek help. 

There are several limitations to this study, including:

  • The study did not include real people, but relied on clinical vignettes to assess the performance of the online symptom checkers. These vignettes included medical terms, which would not necessarily be used by people accessing the sites. Actual patients may sometimes find it difficult to express their symptoms or use different terms. On the other hand, people may refine or add more detail if the advice received was not what was expected.
  • The study might not have captured all the online symptom checkers available.
  • The study does not compare the diagnosis and advice of the online symptom checker to the diagnosis and advise that would have been provided by a doctor.

Overall, it is important to note that symptom checkers should be used as an indicator, and not viewed as an alternative to seeking medical advice, especially if you think it may be a medical emergency.

Like symptom checkers themselves, when it comes to assessing a situation, it is always better to err on the side of caution.

Links To The Headlines

The danger of an online diagnosis: Millions of emergencies are MISSED through symptom checker websites, study warns. Mail Online, July 9 2015

Links To Science

Semigran HL, Linder JA, Mehrotra A, et al. Evaluation of symptom checkers for self diagnosis and triage: audit study. BMJ. Published online July 8 2015

Categories: NHS Choices

Heart attack, stroke and diabetes 'can shorten life by 23 years'

Wed, 08/07/2015 - 17:30

"Suffering from heart disease, stroke and type two diabetes could knock 23 years off life," The Daily Telegraph reports, covering the stark conclusion of a major new UK study. The good news is many chronic diseases, such as stroke, are preventable.

As The Guardian reports, having a history of both heart attack and type 2 diabetes – increasingly common chronic conditions – can shorten life by around a decade.

Researchers looked at more than 130,000 deaths over 50 years. They then estimated the life-shortening effects of different diseases alone and in combination, and found these big three conditions significantly shortened lifespan.

The researchers used a large group and long timespan to make their estimates, giving us confidence in their main conclusions. But they are based on averages.

Each person's risks and lifespan is individual, and it is never too late to improve your health, even if you do have one or more chronic conditions: you can work towards maintaining a healthy weight, exercising more, eating healthily, not smoking, and not drinking too much alcohol

Where did the story come from?

The study was carried out by researchers from the Emerging Risk Factors Collaboration co-ordinated by the University of Cambridge.

It was funded by the UK Medical Research Council, the British Heart Foundation, the British Heart Foundation Cambridge Cardiovascular Centre of Excellence, the UK National Institute for Health Research Cambridge Biomedical Research Centre, the European Research Council, and the European Commission Framework Programme 7.

A number of study authors declared potential financial conflicts of interest relating to funding from pharmaceutical companies, health trust funds and not-for-profit research organisations.

The study was published in the peer-reviewed Journal of the American Medical Association (JAMA).

Both The Guardian and The Daily Telegraph reported the main findings accurately, although neither discussed any limitations. Limitations are important to remind the reader no study is perfect or completely accurate.

The first line of The Telegraph's story told readers the diseases behind the 23-year life loss are largely preventable for "8 out of 10 people". This figure doesn't appear to have been taken from the main study publication, so we can't confirm whether or not this is accurate.

The Telegraph also used the term "heart disease", but the researchers specifically looked at people who had a heart attack (myocardial infarction). While a heart attack can be a common complication of heart disease, not everyone with heart disease will have one.

Nonetheless, it is well known you can reduce your risk of these conditions by living healthily, so there is something you can do about it.   

What kind of research was this?

This analysis of two large cohort studies looked at the impact of diabetes, stroke and heart attack on life expectancy.

The researchers say more and more people are living with one or more conditions that increase their chances of dying early. The conditions of interest were heart attack, stroke and type two diabetes.

The researchers wanted to know the impact on lifespan of having more than one of these three conditions, looking at a large group of people over a significant amount of time.

To do this, they analysed some large and long-term cohort data sets. This is one of the most effective ways of estimating the impact of lifestyle on death across large groups.

The estimates rely on accurate estimates of lifestyle, usually reported in surveys, as well as having a lot of people in the group to boost reliability and generalisablity. 

Such analysis produces averages – what happens to most people most of the time. While very useful, individual risk profiles vary from person to person, and can vary a lot around the average. 

What did the research involve?

The research team analysed two large cohort studies, both of which had rich sources of lifestyle and medical information, allowing them to estimate the impact of different lifestyles and diseases on life expectancy.

The first and largest cohort was from the Emerging Risk Factors Collaboration. This had 689,300 participants from 91 cohorts, covering around 50 years of survey data from 1960-2007. This collected information on 128,843 deaths up to April 2013. The average age was 53, and most participants were from Europe (69%) or North America (24%).

The second cohort was from the UK Biobank. It was a little smaller, but more relevant to the UK. It had data on 499,808 participants with survey-derived lifestyle information spanning from 2006-10. Data on 7,995 deaths was gathered, the latest from November 2013. The average age was 57, and all from the UK.

Death rates were calculated for those with a history of two or more of the following:

  • diabetes mellitus
  • stroke
  • heart attack

The impact on lifespan of having each of the three conditions at different ages, alone or in combination, was estimated independently in both cohorts and then compared.  

What were the basic results?

In men aged 60, a history of any two of the three conditions was associated with a 12-year lower life expectancy. A history of all three of these conditions was associated with 15 years of reduced life expectancy. The estimates were similar for women: 13 years lost for two conditions and 16 years for three.

Life lost was greatest if the history of the conditions was present earlier in life. Estimates in this study started at 40 and ran through until 95.

The highest estimate of life loss was 23 years, the figure picked up by The Telegraph. This related to men aged 40 with a history of diabetes, stroke and heart attack. The loss was only slightly lower in women with the same age and conditions, at 20 years.

Broadly speaking, the impact on risk of death from the three conditions was similar in both cohorts. The researchers found risk of death doubled with one condition, was four times as high with two conditions, and eight times higher with all three. This showed the risk effects were piling on top of each other in an exponential manner, rather than overlapping.

How did the researchers interpret the results?

The authors made three main interpretations. First, because of the addition nature of the results, they concluded that, "Our results emphasise the importance of measures to prevent cardiovascular disease in people who already have diabetes, and, conversely, to avert diabetes in people who already have cardiovascular disease."

Second, they said the shortening of life as a result of the three conditions studied was "of similar magnitude to those previously noted for exposures of major concern to public health, such as lifelong smoking (10 years of reduced life expectancy) and infection with the human immunodeficiency virus [HIV] (11 years of reduced life expectancy)."

Finally, they said there were important differences between men and women. "For men, the association between baseline cardiovascular disease (i.e. a history of stroke or MI) and reduced survival was stronger than for women, whereas the association between baseline diabetes and reduced survival was stronger for women." 

Conclusion

This study used two large cohort-derived data sets to estimate the number of years of life lost as the result of a history of heart attack, stroke or diabetes across different ages.

The study's large size, relevance to the UK and long-term follow-up increases our confidence in its conclusions and their relevance to England and Wales. As with all studies, it has limitations, but these were relatively small and unlikely to affect the main conclusions.

This study shows a history of stroke, type 2 diabetes and heart attack can significantly shorten life expectancy, especially if these conditions are developed earlier in life, at around the age of 40.

But the good news is this is preventable – you can act now to minimise your risk of developing each of these conditions by maintaining a healthy weight, taking more exercise, eating healthily, stopping smoking, and not drinking too much alcohol.

Find out how you can reduce your risk of developing type 2 diabetes or having a heart attack or stroke

Links To The Headlines

Unhealthy lifestyle can knock 23 years off lifespan. The Daily Telegraph, July 7 2015

Heart disease plus diabetes can knock more than a decade off your life. The Guardian, July 7 2015

Links To Science

The Emerging Risk Factors Collaboration. Association of Cardiometabolic Multimorbidity With Mortality. JAMA. Published online July 7 2015

Categories: NHS Choices

People may age at different rates

Wed, 08/07/2015 - 15:20

“Ageing rates vary widely, says study,” BBC News reports. For 12 years, researchers tracked a range of biomarkers associated with the ageing process.

Biomarkers are indicators of how well certain biological processes or systems are functioning.

In this study, the researchers described age-related biomarkers as signs of “gradual and progressive deterioration of integrity across multiple organ systems”.

The biomarkers used included cholesterol levels, gum health and body mass index, among others.

The idea being that, for example, your chronological age could be 30, but you could have the cholesterol levels of a typical 50-year-old.

Researchers looked at just over 1,000 mainly white adults in New Zealand followed from birth to age 38, and information on the biomarkers was collected from the ages of 26 to 38.

The study found that people who had a higher “biological age” also had a higher “pace of biological ageing”. Both were associated with poorer physical and cognitive function, feeling less healthy, and looking older at age 38.

These early stage results will need to be confirmed in larger and broader samples. The idea is that the methods used in the study could eventually be useful in assessing the effectiveness of any future anti-ageing treatments.

The obvious question is: What can people do to slow down their pace of ageing? There is currently no definitive answer to that question. What we do know is regular exercise, a balanced diet and maintaining a healthy weight will give you the best chance of keeping healthy.

 

Where did the story come from?

The study was carried out by researchers from Duke University and other research centres in the US, UK, Israel and New Zealand. It was funded by the US National Institute on Aging, UK Medical Research Council and the Jacobs Foundation. The New Zealand centre received funding from the New Zealand Health Research Council, and another author received support from the Yad Hanadiv Rothschild Foundation.

The study was published in the peer-reviewed journal Proceedings of the National Academy of Sciences (PNAS) of the USA. The study has been published on an open-access basis, so it is free to read online or download as a PDF.

While the majority of the UK media’s reporting of the study was accurate and informative, the Mail Online decided to go on a flight of fancy with the question: “Has science finally cracked the secret of eternal youth?” The obvious answer being: “No”.

 

What kind of research was this?

This was an analysis of data from a cohort study, which aimed to develop ways to assess “biological ageing” in young adults.

The global population is ageing, and increasing age is linked to more disease and disability. Because of humans’ long life span, much of the research into ageing is done in animals with short lifespans, or in older adults, many of whom already have age-related illnesses. The researchers say that one of the reasons why younger people are not studied is that assessing biological ageing in this age group is controversial, as there are various possible indicators, and findings have been mixed. They wanted to see if they could develop reliable ways to do this.

If there were such measurement tools, researchers would like to use these to give an early indication of whether any new “anti-ageing” treatments might be working. This would be quicker than having to wait until people develop age-related diseases or to see how long they live.

This is an appropriate approach to developing these measures, but ideally the research would continue to follow up people, to see if their measures correctly predict health in later life, or their lifespan.

 

What did the research involve?

The researchers studied 1,037 adults from Dunedin in New Zealand, who had been followed up from birth to age 38. They assessed a range of biological characteristics tested at age 26, 32 and 38, to see if some people seemed “biologically older” than others of the same age, and whether people aged at different rates.

The researchers first looked at biological age, using what was known as the “Klemera-Doubal method”, which had been shown to be a better predictor of risk of death than a person’s age alone in a previous US study. This method assesses 10 biological characteristics, including tests of lung function, blood pressure and cholesterol, among others.

They used the Klemera-Doubal method to assess biological age in their study participants at age 38. They then looked at 18 different biological characteristics measured in participants at ages 26, 32 and 38, to see how much they had changed. The characteristics assessed are ones which change with age. They included assessments of the heart and blood (cardiovascular), metabolic and immune systems, as well as the kidneys, liver, gums, lungs and DNA. Some of these characteristics were also included in the biological age calculation.

They used this information to calculate each person’s “pace of ageing” compared to the average change over one year within the group. They then compared whether those with an older Klemera-Doubal biological age showed a more rapid “pace of ageing” than those with a younger biological age.

Finally, they compared physical and cognitive function, and self-rated health among those with different biological ages or pace of ageing. They also got blinded raters to guess how old individuals were from a photo, to see if this differed among those with different biological ages or pace of ageing.

 

What were the basic results?

The researchers found that, according to the Klemera-Doubal method, their sample of 38-year-olds had biological ages ranging from 28 to 61 years old.

The 18 biological characteristics they followed showed different rates of change in different people from the ages of 26 to 38. They calculated people’s “pace of ageing” based on these characteristics, and found that some people showed zero years of biological change per chronological year, while others showed almost three years of biological change per chronological year.

People with an older biological age had a more rapid pace of ageing from the ages of 26 to 38 than those with a younger biological age. Each year increase in biological age compared to actual age added a 0.05 year increase in pace of ageing. So, a person who was 38 but had a biological age of 40 was estimated to have aged 1.2 years faster over the past 12 years, compared to a person who had a biological age of 38.

They also found that at age 38, those with a higher biological age or faster pace of ageing performed less well on physical and cognitive function tests than those with a younger biological age or slower pace of ageing. Those with a higher biological age or faster pace of ageing had also rated themselves as less healthy and were estimated to be older based on facial appearance by volunteers who did not know the participants’ ages.

 

How did the researchers interpret the results?

The researchers concluded that, “young individuals of the same chronological age varied in their 'biological ageing'” and that “already, before midlife, individuals who were ageing more rapidly were less physically able, showed cognitive decline and brain ageing, self-reported worse health, and looked older”. They suggest that these measures of biological ageing in young adults could be used to identify causes of ageing and evaluate anti-ageing treatments.

 

Conclusion

This study has developed a new method of assessing the “pace of biological ageing” over time in adults under 40. It showed an association between this measure and another measure of biological age, as well as physical and cognitive function, and how healthy people felt and how young they looked.

In some ways, these results are unsurprising, as the biological measures assessed are measures relating to health, such as blood pressure and cholesterol, as well as measures of fitness and weight.

These results will also need to be confirmed in larger and broader samples – for example, of different ethnicities – as the study was in mainly white participants. Longer-term studies would also be needed to assess whether these measures predict health outcomes at later ages, or lifespan.

As for practical implications, this sort of measure is most likely to be used in research. It’s unlikely that individuals will be able to use this method to calculate their biological age, as the measures used need blood and other clinical tests, and getting the “pace of ageing” needs measurements collected over 12 years. We also don’t yet know whether interventions, either lifestyle or drug treatments, will impact this “biological ageing”.

Based on what we already know, to maximise your chances of living a long and healthy life, taking steps such as maintaining a healthy weight, eating a varied and balanced diet, keeping physically active, moderating your consumption of alcohol and avoiding smoking are likely to be your best bet. 

Links To The Headlines

Ageing rates vary widely, says study. BBC News, July 7 2015

Why you might be 20 years older than your actual age. The Daily Telegraph, July 6 2015

Old before your time? People age at wildly different rates, study confirms. The Guardian, July 6 2015

Has science finally cracked the secret of eternal youth? Study finds some people can halt - and even REVERSE - the ageing process during their thirties. Mail Online, July 7 2015

Think you look old? It might be your ‘biological age’. Metro, July 7 2015

How to stay young: The 38-year-olds whose biological ages range from 28 to 61. Daily Express, July 6 2015

Links To Science

Belsky DW, Caspi A, Houts R, et al. Quantification of biological aging in young adults. PNAS. Published online July 6 2015

Categories: NHS Choices

Reports that 1 pregnant woman in 3 in UK binge drink unconfirmed

Tue, 07/07/2015 - 12:00

"A third of British women risk doing severe harm to their unborn babies by binge drinking during pregnancy," the Mail Online reports. While a concerning statistic, the evidence behind the headline is perhaps not as clear-cut as the Mail would lead its readers to believe. 

This story has been prompted by the publication of a study comparing just over 17,000 women's alcohol consumption before and during pregnancy in the UK, Ireland, Australia and New Zealand. It also looked at which groups of women were more likely to report drinking alcohol in pregnancy.

While the overall study population was large, an overlooked fact not made clear in the media was that the study only included data from 651 women from the UK. The study also collected this data over a relatively long time – between 2004 and 2011 – and drinking habits may have changed since then.

Out of these 651 women, a third reported binge drinking (defined as drinking six units or more in one sitting) in their first trimester. Reassuringly, in all countries surveyed, this figure dropped dramatically in the second trimester, to around just 1%.

This pattern could suggest that women may not have known they were pregnant at the time of binge drinking, and stopped once they found out. Whether pregnant or not, it is best to avoid binge drinking.

Current NICE recommendations are that women abstain from drinking alcohol in the first trimester of pregnancy, as it can increase the risk of miscarriage. It is also linked to premature birth, and drinking heavily through pregnancy can result in foetal alcohol syndrome.

If you are pregnant and having problems controlling your drinking, you should contact your GP for advice.

 

Where did the story come from?

The study was carried out by researchers from Cork University Maternity Hospital and other hospitals and research centres in Ireland, the UK, Australia and New Zealand. The studies in the individual countries were funded by different governmental and charity and research bodies. For example, in the UK, funding was provided by the National Health Service (NHS), Biotechnology and Biological Sciences Research Council, University of Manchester Proof, Guy's and St Thomas’ Charity, Tommy's charity and Cerebra UK.

The study was published in the peer-reviewed BMJ Open. This is an open-access journal, so the study is free to read online or download as a PDF.

The UK media focuses on the UK results, but none appear to report that these figures come from just 651 women, and data was collected over a long time period (2004-2011). This is probably too small a sample size to confidently extrapolate it to current drinking habits among all pregnant women in the UK, as most of the headline writers have done.

Only The Guardian points out that the reported level of binge drinking dropped to around 1 in 100 women in the second trimester.

While not assessed in the study, this could suggest that the vast majority of women stopped binge drinking once they realised they were pregnant, to prevent harm to their baby.

The researchers do call for better ways to assess alcohol intake in pregnant women, to get a more reliable estimate of how many women do drink in pregnancy. For example, they suggest the possibility of a biological test, which would not require a woman to self-report consumption.

What kind of research was this?

This was an analysis of data collected in both prospective and retrospective cohort studies. It aimed to identify how many women drank alcohol before and during pregnancy in multiple countries, and identify the characteristics of women who were more likely to drink in pregnancy.

This is a suitable approach to assessing this question. Prospective studies are more likely to be reliable, as they enrol people and then continue to assess their habits, as opposed to asking them about the (sometimes distant) past.

It is difficult to assess people’s alcohol consumption, as it relies on people being truthful and accurate about how much they drink. This may be even more difficult in pregnant women, as they may feel guilt or stigma associated with drinking alcohol in pregnancy, making them less likely to report it.

The researchers hoped that by looking at results collected in different ways from countries that are generally similar, they might get an idea of which methods of assessing alcohol consumption in pregnancy give the most consistent results.

In addition, estimates from different studies may be affected by different ways in which drinking was measured, meaning that estimates are not entirely comparable.

 

What did the research involve?

The researchers used data collected in three studies – two retrospective studies from Ireland and one international prospective study.

The Growing up in Ireland (GUI) study was a national survey of a sample of mothers of 10,953 infants aged six to nine months, carried out in 2008 and 2009. Interviews were carried out face-to-face by a trained researcher. They were asked if they drank during pregnancy and, if so, how much on average they drank per week (pints of beer or cider, glasses of wine, measures of spirits or alcopops) in each trimester.

The Pregnancy Risk Assessment Monitoring System Ireland (PRAMS Ireland) study surveyed a sample of 718 women who had given birth to a live baby and been discharged from Cork University Maternity Hospital in 2012. These women completed three postal surveys between two and nine months after the birth of their baby. The surveys included questions about whether they drank alcohol, how much (glasses or bottles) of different types of alcohol they drank and how often (occasions per week or month) in the three months before pregnancy, and in each trimester.

The international Screening for Pregnancy Endpoints (SCOPE) study included 8,531 healthy women who had their first baby from 2004 to 2011 in Ireland, the UK, Australia and New Zealand. The study did not include women who had multiple pregnancies (e.g. twins), or had various medical complications, such as being at high risk of pre-eclampsia, or who had a baby that was small for its gestational age or born pre-term. Research midwives interviewed the participants at 15 and 20 weeks into their pregnancy. They asked the women if they drank alcohol before pregnancy or earlier than 15 weeks, or were still drinking alcohol at the time of the interview. If they reported drinking at any of these points, they were asked how many units or "binges" per week they were drinking up to the time of interview. If they reported stopping drinking alcohol during the study, they were asked when they stopped.

The researchers compared results from the different studies. They defined one unit of alcohol as 8-10g of pure alcohol, which was equivalent to one glass of wine (about 100-125ml), one small glass of sherry, a single "nip" of spirits, or half a pint of regular-strength lager. A can or small bottle/glass of regular-strength beer (300-330ml, 4-5% alcohol) was equivalent to 1.5 units of alcohol, and a bottle of alcopop was equivalent to 2 units of alcohol. Alcohol intake was classified as occasional (1-2 units/week), low (3-7 units/week), moderate (8-14 units/week) or heavy (greater than 14 units/week). Binge drinking was considered to be consuming six or more units per occasion.

The studies also collected other information from the women, and the researchers looked at what characteristics were more common among women who reported drinking alcohol during pregnancy.

 

What were the basic results?

There was variation in the amount of alcohol the women reported consuming across the different countries and across groups of women with different characteristics.

When looking at Ireland, women in the SCOPE study reported the highest levels of drinking:

  • 90% of Irish women in the SCOPE study reported drinking before pregnancy, compared to 77% in PRAMS Ireland.
  • 82% of Irish women in the SCOPE study reported drinking during pregnancy, compared to 46% in PRAMS Ireland and 20% in GUI.
  • 59% of Irish SCOPE participants reported binge drinking before pregnancy, and 45% during pregnancy.
  • By the second trimester, the proportion of Irish women reporting drinking alcohol in SCOPE had dropped to 29%, similar to the level in the PRAMS study (31%), and women were drinking less.
  • The proportion of Irish women drinking remained similar across the trimesters in the PRAMS (about 30%) and GUI studies (about 10-15%).

When looking across different countries within the SCOPE study:

  • Women in Ireland were most likely to report drinking pre-pregnancy (90%) or binge drinking pre-pregnancy (59%), and those in Australia least likely (drinking 53%, bingeing 11%).
  • Women in Ireland were also most likely to report drinking at some point during pregnancy (82%) or binge drinking at some point during pregnancy (45%).
  • 75% of women from the UK reported drinking at some point in pregnancy and 33% reported binge drinking at some point in pregnancy.
  • Binge drinking was much less common in the second trimester (average 0.4% of women) than the first trimester (average 23%) across all countries.

When looking at the characteristics of those who drank:

  • Non-Caucasian women in all studies were less likely to drink alcohol during pregnancy than Caucasian women.
  • Women who smoked were more likely to drink alcohol during pregnancy in all three studies.

 

How did the researchers interpret the results?

The researchers concluded that: "alcohol use during pregnancy is prevalent and socially pervasive in the UK, Ireland, New Zealand and Australia". They suggest that this shows low adherence to guidelines recommending complete abstinence or only low consumption, and that new policies and interventions are needed to reduce women’s alcohol consumption both before and during pregnancy. They also note that research is needed to identify more reliable ways to assess alcohol consumption in pregnancy, so they can more accurately tell how many women do drink during pregnancy.

 

Conclusion

This study provides information on reported alcohol consumption among pregnant women in four different countries. The study’s strengths are the relatively large number of women assessed overall (over 17,000) and that at least some of the data was collected prospectively.

The studies collected data on alcohol consumption in different ways – for example, in face-to-face interviews or by post – and interviews were carried out by either midwives or researchers. They also used different questions about alcohol consumption. This may mean that results are not directly comparable across the studies. The researchers were interested in whether, despite these different methods, there would be similar results across the studies. For example, the fact that women who smoked were more likely to report drinking alcohol in pregnancy across the studies suggests that this is more likely to be a reliable finding.

The researchers note that:

  • Their study included women who may be less disadvantaged than the general population, so results may not be as representative of more disadvantaged populations.
  • They only included women whose baby was born alive. This excludes women who had a miscarriage, and therefore may exclude the heaviest drinkers, as heavy or chronic alcohol use in early pregnancy has been linked to increased miscarriage risk.

It is difficult to assess people’s alcohol consumption, as it relies on people being truthful and accurate about how much they drink. This may be even more difficult in pregnant women, as they may feel guilt or stigma associated with drinking alcohol in pregnancy, making them less likely to report it.

Cultural differences and possible differences in guidance about alcohol consumption in pregnancy across the different countries may have influenced the results. The studies collected data across a wide time period, particularly the SCOPE study, which collected data from 2004 to 2011. Alcohol consumption may also have varied over this period.

Although the study was large overall, the number of women from some countries was small. For example, only 651 women from the UK were included, and 1,159 from Australia. Therefore, results may not be representative of the whole pregnant population in these countries.

The overall pattern of results is somewhat skewed, due to larger amount of data relating to women from Ireland and New Zealand.

Current UK NICE guidance recommends that women planning a pregnancy and pregnant women avoid drinking alcohol in the first three months (trimester) of pregnancy because it may increase risk of miscarriage.

If women choose to drink during pregnancy, they should drink no more than 1 to 2 UK units once or twice a week. NICE notes that there is still uncertainty regarding a safe level of alcohol consumption in pregnancy, but there is no evidence that this low level causes harm to the unborn baby.

Pregnant women should avoid getting drunk or binge drinking (drinking 5 standard drinks or 7.5 UK units on a single occasion), as this may harm the unborn baby. 

Links To The Headlines

One in three women admit to binge-drinking during pregnancy: Experts call for new guidelines advising no alcohol at all following findings. Mail Online, July 7 2015

Nearly a third of pregnant women in the UK binge drink, research reveals. The Independent, July 7 2015

Pregnant women should be tested for alcohol amid binge drinking fears. The Daily Telegraph, July 6 2015

Concern over levels of drinking during pregnancy raised by studies. The Guardian, July 6 2015

Links To Science

O’Keeffe LM, Kearney PM, McCarthy FP, et al. Prevalence and predictors of alcohol use during pregnancy: findings from international multicentre cohort studies. BMJ Open. Published online July 6 2015

Categories: NHS Choices

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